^e\v    York. 


Columbia  SSnibersitp 

m  tfje  Citp  of  i^etti  |9orfe 
College  of  ^ Jpsiiciansf  anb  ^urgeonsf 


Br.€trttiinS?,Cragm 

1859-1918 


ESSENTIALS  OF  PIYSIOLO&Y. 

BY 
Instructor  in  Physiology, .  University  of  Pennsylvania,  etc. 


Medical  Record,  New  York,  Aug.  4tli,  1888. 
We  have  no  hesitation  in  saying  that  it  is  the  best  condensation 
of  physiological  knowledge  we  have  yet  seen. 


Medical  Standard,  Chicago,  June,  1888. 

Hare's  Questions  on  Physiology  is  an  excellent  work  for  Quiz 
purposes.      It  is  lucid  and  terse. 


Medical  and  Surgical  Reporter,  June,  1888. 

This  book  differs  from  most  works  intended  for  the  use  of  medical 
students  in  that  it  imitates  the  style  of  the  Quiz  Class,  being  pre- 
pared in  the  form  of  Questions  and  Answers.  The  matter,  as  might 
be  expected  from  the  reputation  of  the  author,  is  most  excellent. 
The  manner  is  dogmatic  and  wejl  suited  to  the  needs  of  the  student 
preparing  for  examination.  The  author  justifies  his  method  by 
citing  the  existing  state  of  medical  education  in  this  country,  and 
some  of  the  statements  by  the  fact  that  physiology  is  a  branch  of 
science  in  which  change  is  continually  occurring,  so  that  a  definite 
answer  to  certain  questions  is  not  unlikely  to  differ  from  the  opinion 
of  some  authority.  The  needs  of  medical  students,  however,  neces- 
sitate definite  answers,  and  those  given  in  this  book  represent  very 
well  the  present  state  of  knowledge  in  physiology. 


Boston  Medical  and  Surgical  Journal,  May  10,  1888. 

In  some  points  the  information  is  surprisingly  good  and  fresh. 
In  fact,  there  are  but  few  points  on  which  serious  exceptions  need 
be  taken. 


Saunders'  Question  Compends. 

Arranged  in  the  form  of  Questions  and  Answers. 

Prepared  especially  for  Students  of  Medicine.  Cloth,  $1.00; 
Interleaved,  for  taking  notes,  $1.25.  For  sale  by  all  booksellers, 
or  "will  be  sent,  post-paid,  on  receipt  of  price,  by 

W.  B.  SAUNDERS,  Publisher, 

33  and  35  South  Tentk  Street,  PMladelpliia. 

The  Advantage  of  Questions  and  Answers. 

The  usefulness  of  arranging  the  subjects  in  the  form  of  questions 
and  answers  will  be  apparent,  since  the  student,  in  reading  the 
standard  works,  often  is  at  a  loss  to  discover  the  important  points 
to  be  remembered,  and  is  equally  puzzled  when  he  attempts  to  for- 
mulate ideas  as  to  the  manner  in  which  the  questions  could  be  put 
in  the  examination-room. 

Each  Book  Contains  over  1000  Questions  and  Answers. 

Just  the  Books  you  want  for  Self-Quizzing. 

Absolutely  Necessary  in  preparing  for  Examination  or  for 

use  as  Reference  Books. 


SAUNDERS'  QUESTION  COMPENDS. 

The  Latest,  Cheapest,  aad  Best  Illustrate i  Series  of   Oofiipends. 

^LIST  OF  VOLUMES. 
No.   1.— Essentials    of  Physiology.      By   H.    A.    Hare,    M.D. 

Demonstrator  of  Therapeutics  and  Instructor  in  Physical  Diagno- 
sis in  the  Medical  Department,  and  Instructor  in  Ph3^siology  in. 
the  Biological  Department  of  the  University  of  Pennsylvania; 
Ph3'sician  to  the  Dispensary  for  the  Diseases  of  Children,  and 
Assistant  Physician  to  the  Nervous  Dispensary  of  the  University 
Hospital  ;  Physician  to  St.  Clement's  Dispensary  and  Hospital ; 
Member  of  the  American  Society  of  Physiologists  and  of  the 
American  Society  of  Naturalists. 
No.  2. —Essentials  of  Surgery.  Containing,  also,  Surgical  Land- 
marks^ Minor  and  Operative  Surgery.,  and  a  Complete  Descrip- 
tion together  with  full  Illustration  of  the  Handkerchief  and  Boiler 
Bandage..  By  Edward  Martin,  A.M.,  M.D.,  Instructor  in 
Operative  Surgery  and  Lecturer  on  Minor  Surgery,  University 
of  Pennsylvania  ;  Surgeon  to  the  Out-patients'  Department  of  the 
Children's  Hospital ;  and  Surgeon  Registrar  of  the  Philadelphia 
Hospital. 


SAUNDERS'  QUESTION  OOMPENDS. 

LIS  T  O  F  VO  LUME  S . — (  Continued. ) 
No.  3.— Essentials  of  Anatomy.  lucliiding  Visceral  Anatomy. 
O^er  three  liiiudred  printed  pages,  with  one  hundred  and  twenty- 
five  illustrations.  By  Chas.  B.  Nancrede,  M.D.,  Senior  Sur- 
geon to  Episcopal  Hospital  ;  Surgeon  to  Jefferson  College  Hos- 
pital, Formerly  Lecturer  on  Osteology,  etc.,  in  Medical  Depart- 
ment University  Penna.  ;  Late  Professor  of  General  and  Ortho- 
pedic Surgery  in  Philadelphia  Polyclinic  ;  and  Lecturer  on 
Surgery  in  the  Dartmouth  Med.  College,  etc.  etc. 
No.  4. — Essentials  of  Medical  Chemistry.  Organic  and  Inorganic, 
containing  also  Questions  on  Medical  Physics,  Chemical  Philos- 
ophy, Analj'tical  Processes,  Urinalysis,  and  Toxicology.  By 
Lawrence  Wolff,  M.D.,  Demonstrator  of  Chemistry  Jefferson 
Medical  College,  Visiting  Physician  to  German  Hospital  of  Phil- 
adelphia, Member  of  Philadelphia  College  of  Pharmacy,  etc.  etc. 

No.  5o— Essentials  of  Obstetrics.  By  W.  Easterly  Ashton, 
M.D.,  Clinical  Demonstrator  of  Obstetrics  in  the  Jefferson  Med- 
ical College,  Chief  of  Clinic  for  Diseases  of  Women,  Jefferson 
College  Hospital,  Philadelphia. 

OTHERS  IN  PREPARATION. 


This  new  series  of  Compends  for  Students,  for  use  in  Quiz 
Classes  and  Examination  rooms,  are  bound  to  become  popular,  con- 
venient for  the  pocket,  illustrated  with  fine  wood-cuts  and  containing 
information  not  to  be  had  in  any  other  works  of  the  size. 

At  the  present  time,  when  the  student  is  forced  by  the  rapid 
progress  of  medical  science  to  imbibe  an  amount  of  knowledge 
which  is  far  too  great  to  permit  of  any  attempt  on  his  part  to  master 
it,  a  book  which  contains  the  "essentials''  of  a  science  in  a  concise 
yet  readable  form  must  of  necessity  be  of  value. 

Intended  to  assist  Students  to  put  together  the  knowledge 
they  have  already  acquired  by  attending  lectures. 

Do  not  fail  to  see  these  new  Compends. 
Specially  prepared  for  the  use  of  Students  of  any  Medical 

College.  ^ 

Manuals  of  this  kind  are  in  no  way  intended  to  supplant  any  of 
the  text-books,  but  to  contain,  as  its  title  declares,  the  essence  of 
those  facts  with  which  the  average  student  must  be  familiar. 


SAUNDERS' 
QUESTION  COMPENDS.    No.  5 

OBSTETRICS. 


QUESTIONS  AND  ANSWERS 


ESSENTIALS  OF  OBSTETRICS 


PREPARED   ESPECIALLY    FOR 


STUDENTS  OF  MEDICINE. 


BY 

WILLIAM  EASTERLY  ASHT0:N^,  M.D., 

DEMONSTBATOE  OF   CLINICAL  OBSTETRICS   IN   THE   JEFFERSON    MEDICAL   COLLEGE  ;   CHIEF 

OF  CLINIC  FOR  DISEASES  OF   WOMEN  IN  THE  JEFFERSON  MEDICAL  COLLEGE  HOSPITAL  ; 

MEMBER   OF  THE   OBSTETRICAL   SOCIETY   OF   PHILADELPHIA,    ETC. 


WITH  ILLUSTRATIONS. 


PHILADELPHIA: 

W.  B.  SAUNDERS. 

1888. 


Entered  according  to  the  Act  of  Congress  in  the  year  1888,  by 

W.  B.  SAUXDEES, 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington. 


DOENAN,    PEINTEB, 
PHILADELPHIA . 


TO 

Dr.  SAMUEL  KEEN  ASHTON, 

THE  KIND  AND  INDULGENT  FATHEK,  THE  TRUE  FRIEND, 

THIS  MANUAL 

IS  AFFECTIONATELY  DEDICATED 

BY  HIS  SON 

THE  AUTHOR, 

IN  APPRECIATION  OF  THE    EXAMPLE    OF   HIS   LIFE  AND  OF  HIS 
MANY  ACTS  OF  PATERNAL   CARE. 


(V) 


PREFACE. 


This  manual  is  to  assist  the  student  in  mastering  the 
essentials  of  the  science  and  art  of  obstetrics.  As  a  work 
of  this  kind  must  of  necessity  be  limited  in  its  character, 
the  author  has  relied  upon  his  experience  as  a  teacher  for 
the  selection  of  such  matter  as,  in  his  judgment,  will  prove 
of  most  value. 

He  has  endeavored  to  present  in  a  clear  and  concise  man- 
ner the  views  of  the  present  day,  and  the  standard  works  of 
Parvin,  Goodell,  Lusk,  Playfair,  Hirst's  American  System  of 
Obstetrics,  Winckel's  Diseases  of  Women,  Hart  and  Barbour, 
Thomas,  Emmet,  and  Charpentier's  Cyclopcedia  of  Obstetrics 
and  Gynecology  have  been  consulted.  * 

The  chapter  on  obstetric  auscultation  and  palpatio7i  has  been 
fiilly  discussed  and  embodies  the  didactic  and  bedside  in- 
structions of  Prof.  Parvin. 

In  the  preparation  of  the  chapter  on  Ccesarean  section  the 
writer  is  indebted  to  an  article  written  by  Dr.  Gustav 
Zinke,  the  illustration  showing  the  deep  and  superficial 
uterine  sutures  being  taken  from  the  same  source. 

He  is  also  indebted  to  his  friend  Dr.  Henry  H.  Sherk  for 
several  of  the  illustrations,  and  to  his  former  student  Dr. 
James  C.  Bloomfield  for  the  preparation  of  the  index. 

William  Easterly  Ashton. 

222  SoTTTH  Eighth  Street,  Philadelphia, 
November,  1888. 

(vii) 


CONTENTS. 


Introduction 17 

Anatomy  of  tlie  pelvis 17 

The  pelvic  joints 18 

The  pelvic  inlet .        .19 

The  pelvic  outlet 20 

The  pelvic  cavity 21 

The  obliquity,  planes,  and  axes  of  the  pelvis  ...  23 

The  soft  parts  of  the  pelvis 25 

The  female  generative  organs 28 

Embryology 30 

Development  of  the  female  generative  organs        .        .       *.  34 

External  organs 34 

Internal  organs 35 

Development  of  the  embryo  and  foetus 37 

Physiology  of  the  foetus 39 

The  foetal  head  and  trunk 43 

The  foetal  head 43 

•      The  foetal  trunk 45 

The  attitude  and  presentation  of  the  foetus     ....  46 

Puberty,  nubility,  ovulation,  menstruation,  and  menopause  .  46 

Pregnancy 53 

Conception        .         .       • 53 

Changes  in  the  maternal  organism 65 

Signs  and  diagnosis  of  pregnancy 59 

Differential  diagnosis  of  pregnancy  .        .        .        .65 

Multiple  pregnancy 69 

Diagnosis  of  multiple  pregnancies    ....  70 

Diseases  of  pregnancy 71 

Nausea  and  vomiting         .         .  "      .        .        .         .71 

(ix) 


X                                                CONTENTS. 

PAGE 

Hyperemesis 

72 

CEdema.    Varicose  veins  .        .        .        .        .        . 

75 

Salivation.    Relaxation  of  the  pelvic  joints     . 

76 

Diseases  of  the  organs  of  generation 

77 

Diseases  of  the  ovum 

81 

Myxomatous  degeneration  of  the  placenta,  or  hydatidi- 

form  mole 

81 

Polyhydramnios 

83 

Abortion 

85 

Ectopic  development  of  the  ovum  .        .        . 

92 

Placenta  praevia 

97 

Accidental  hemorrhage 

101 

Eclampsia . 

102 

Labor 

107 

Mechanism  of  labor 

115 

Management  of  labor 

134 

Anaesthesia 

134 

Preliminary  preparations  .         .         .         .         . 

135 

First  stage 

136 

Second  stage 

137 

Preservation  of  the  perineum     . 

139 

Thirdj  or  placental  stage 

141 

Asphyxia  neonatorum 

143 

Management  of  occipito-posterior  positions     . 

146 

Face  presentations 

146 

Brow  presentations 

147 

.    147 

Antisepsis 

150 

Labor  and  puerperal  state         .... 

150 

The  pathology  of  labor    .         .  '       . 

151 

Precipitate  labor 

151 

Prolonged  labor         ...... 

.     152 

.    156 

Dorsal  displacement  of  the  arm 

156 

Excessive  development  of  the  foetus 

.     156 

Premature  ossification        .... 

.     156 

Large  size  of  the  body        ,        ,        .        . 

157 

CONTENTS. 


XI 


Large  size  of  the  foetal  head 
Hydrocephalus 
Monstrosities 

Dystocia  in  plural  deliveries 
Prolapse  of  the  funis  . 
Deformities  of  the  pelvis 
Rupture  of  the  uterus      .         .         . 
Inversion  of  the  uterus    . 
Post-partum  hemorrhage 

Primary  hemorrhage 
Secondary  hemorrhage 
Puerperal  septicaemia 
Obstetric  operations 

The  induction  of  premature  labor 
The  induction  of  abortion 
Version,  or  turning  . 
Cephalic  version 
Pelvic  version    . 
Podalic  version  . 
The  forceps 
Embryotomy     . 
The  Csesarean  section 
The  post-mortem  Csesarean  section 
Post-mortem  extraction  through  the  natural  passages 


PASE 

157 

157 

159 

164 

166 

169 

176 

178 

180 

180 

182 

182 

188 

188 

190 

192 

192 

194 

195 

198 

205 

209 

212 

213 


ESSENTIALS  OF  OBSTETRICS. 


INTRODUCTION. 

"What  is  obstetrics  ? 

The  care  of  women  during  pregnancy,  labor,  and  in  the  puer- 
peral state. 

What  are  the  synonyms  for  obstetrics  ? 

Tocology,  parturition,  midwifery,  accouchement,  and  maieutics. 

What  do  you  mean  by  the  science  and  art  of  obstetrics  ? 

"  Obstetric  science  means  the  classified  knowledge  of  the  laws 
of  human  reproduction ;  obstetric  art  includes  the  rules  drawn 
from  those  laws  or  from  intelligent  experience." 

ANATOMY  OF  THE  PELVIS/ 

What  bones  form  the  anatomical  pelvis  ? 
The  coccyx,  sacrum,  and  the  ossa  innominata. 

What  bones  form  the  obstetric  pelvis  ? 

The  coccyx,  sacrum,  ossa  innominata,  and  the  last  lumbar  ver- 
tebra. 

What  is  meant  by  the  static  pelvis  ? 
The  bony  pelvis. 

What  is  meant  by  the  dynamic  pelvis  ? 

"The  pelvis  in  the  living  subject  and  in  labor." 

1  For  the  anatomical  description  of  the  pelvis  the  student  is  referred  to 
his  text-books. 

2 


18  ESSENTIALvS    OF    OBSTETRICS. 

How  is  the  pelvis  divided  ? 

Into  two  parts  :  one,  the  upper,  false  or  greater  pelvis ;  the  other, 
the  lower,  true  or  lesser  pelvis. 

What  is  the  dividing  line   hetween  the  true  and  false 
pelvis  ? 

The  ilio-pectineal  line. 

What  are  the  four  cardinal  points  of  Capuron? 

The  right  and  left  sacro-iliac  joints,  and  the  right  and  left  ilio- 
pectineal  eminences. 

What  is  the  promontory  or  sacro-vertebral  angle  ? 

The  prominence  formed  at  the  point  of  articulation  of  the  sacrum 
with  the  spine. 

What  bones  form  the  anterior,  lateral,  and  posterior  walls 
of  the  true  pelvis  ? 

The  anterior  and  lateral  walls  are  formed  by  the  innominate 
bones ;  the  posterior  wall  by  the  last  lumbar  vertebra,  the  sacrum, 
and  coccyx. 

What  is  the  length  of  the  anterior,  lateral,  and  posterior 
walls  of  the  true  pelvis  1 

The  anterior  wall  measures  from  IJ  to  If  inch ;  the  lateral  Si- 
inches;  the  posterior  5  inches,  or,  following  the  curve  of  the 
sacrum  and  coccyx,  5^  inches. 

The  Pelvic  Joints. 

How  many  joints  unite  the  bones  of  the  obstetric  pelvis? 

Seven. 

Name  them. 

One  pubic ;  one  sacro-coccygeal ;  two  sacro-iliac ;  and  three 
sacro-vertebral. 

What  joints  are  amphiarthrodial  ? 

The  pubic,  the  sacro-coccygeal,  the  sacro-iliac,  and  the  articular 
surface  of  the  body  of  the  last  lumbar  and  the  first  sacral  vertebrae. 


ANATOMY    OF    THE    PELVIS.  19 

What  joints  are  arthrodial  ? 

The  two  articulations  formed  by  the  articular  processes  of  the 
last  lumbar  and  first  sacral  vertebrae. 

Are  any  of  the  diameters  of  the  pelvis  increased  or  dimin- 
ished by  movements  in  the  pelvic  joints  ? 

The  antero-posterior  diameter  of  the  outlet  is  increased  by  the 
movement  in  the  sacro-coccygeal  joint;  this  movement  may  occur 
between  the  first  and  second  bones  of  the  coccyx ;  less  frequently 
between  the  second  and  third,  or  between  the  third  and  fourth. 
It  is  probable  that  there  is  a  lessening  of  the  antero-posterior 
diameter  of  the  inlet,  with  an  increase  in  the  corresponding  diame- 
ter of  the  outlet  caused  by  the  elevation  and  depression  of  the 
pubic  joint;  either  by  the  sacrum  moving  forward  upon  an  imag- 
inary transverse  line,  or  by  the  movements  of  the  iliac  bones  on 
the  sacrum  itself. 

What  are  the  functions  of  the  pelvic  joints  ? 

In  addition  to  their  influence  upon  the  pelvic  diameters  already 
referred  to,  they  decompose  forces  received  by  the  lower  extremi- 
ties, and  thus  prevent  sudden  shocks  being  transmitted  directly  to 
the  contents  of  the  pelvis. 

What  changes  occur   in  the  pelvic  joints  during   preg- 
nancy ? 

The  ligaments  become  elongated  and  swollen,  the  fibro-cartilages 
distended  with  serum  and  softened,  and  there  is  a  slight  separa- 
tion between  the  bones.  These  changes  are  most  marked  in  the 
pubic  joint;  they  can  be  demonstrated  by  introducing  the  finger 
into  the  vagina  and  pressing  against  the  inferior  border  of  the 
symphysis,  at  the  same  time  directing  the  patient  to  stand  first  on 
one  foot  and  then  on  the  other ;  the  mobility  can  thus  be  distinctly 
recognized. 

The  Pelvic  Inlet. 

What  is  the  pelvic  inlet  ? 

The  entrance  to  the  cavity  of  the  pelvis. 

How  is  it  bounded  ? 

Posteriorly,  by  the  promontory  and  the  anterior  edge  of  the  alse 


20  ESSENTIALS    OF    OBSTETKICS. 

of  the  sacrum ;  laterally,  by  the  ilio-pectmeal  line ;  anteriorly,  by 
the  ilio-pectineal  eminences,  and  the  posterior  edge  of  the  oblique 
rami  and  body  of  the  pubes. 

What  are  the  synonyms  for  the  inlet  ? 

Margin,  isthmus,  and  superior  strait  or  brim. 

What  is  the  shape  of  the  inlet  ? 

It  is  heart-shaped ;  pointed  in  front,  and  encroached  upon  pos- 
teriorly by  the  promontory. 

What  are  the  diameters  of  the  inlet  ? 

An  antero-posterior ;  a  transverse ;  and  two  oblique  diameters 
(right  and  left). 

Between  what  points  are  the  diameters  taken  ? 

The  antero-posterior  (sacro-supra-pubic,  or  conjugate)  extends 
from  the  upper  border  of  the  symphysis  to  the  centre  of  the  sacro- 
vertebral  angle. 

The  two  oblique  diameters  connect  the  four  cardinal  points  of 
Ca^Duron;  that  starting  from  the  left  sacro-iliac  synchondrosis 
being  named  the  left,  that  from  the  right,  the  right  oblique.  The 
transverse  or  bis-iliac  is  the  widest  measurement  between  the  ilia. 

What  do  the  diameters  of  the  inlet  measure  ? 

Parvin.  Lusk.  Playfair. 

A.  P.,  4.3  to  4.5  inches.  4^  inches.  4.25  inches. 

T.,        5.3  "  5i      "  5.2 

O.,       4.7  to  4.9     ''  5        "  4.8        ** 

What  does  the  circumference  measure  ? 

Parvin,  15.8  inches ;  Lusk,  16  inches. 


The  Pelvic  Outlet. 

How  is  the  pelvic  outlet  bounded  ? 

Posteriorly,  by  the  coccyx;  anteriorly,  by  the  subpubic  liga- 
ment ;  and  on  either  side  by  the  ischio-pubic  ramus,  the  tuberosity 
of  the  ischium,  and  the  sciatic  ligaments. 


ANATOMY    OF    THE    PELVIS  21 

What  is  the  shape  of  the  outlet  ? 

That  of  two  triangles  joined  by  a  common  base. 

What  are  the  diameters  of  the  outlet  ? 

An  antero-posterior ;  a  transverse;  and  two  oblique  diameters 
(right  and  left). 

Between  what  points  are  the  diameters  taken  ? 

The  antero-posterior  (coccy-pubic)  extends  from  the  subpubic 
ligament  to  the  tip  of  the  coccyx.  The  transverse  is  measured 
between  the  inner  borders  of  the  ischial  tuberosities.  The  oblique 
diameters  connect  on  either  side  the  middle  of  the  inferior  sur- 
face of  the  great  sacro-sciatic  liagment  with  the  point  of  union  of 
the  ischio-pubic  rami. 

Are  the  oblique  diameters  of  the  outlet   considered   of 
obstetric  importance  ? 

No ;  owing  to  the  yielding  of  the  sciatic  ligaments. 

What  do  the  diameters  of  the  outlet  measaire  ? 

Parvin.  iMsk.  Playfair. 


A.  P.,  4.3  inches. 

3|  inches. 

5.0  inches. 

4.1       << 

4.2       " 

0., 

Is  the  antero-posterior  diameter  increased  during  labor  ? 

Yes ;  from  one-half  to  -one  inch,  by  the  retrocession  of  the  coccyx. 

What  does  the  circumference  of  the  outlet  measure  ? 
Thirteen  inches  and  a  half 


The  Pelvic  Cavity. 

How  is  the  pelvic  cavity  bounded  ? 

By  the  inlet  above  and  the  outlet  below. 

What  is  its  shape  ? 

Irregularly  barrel-shaped. 


22  ESSENTIALS    OF    OBSTETRICS. 

Is  the  bony  wall  of  the  cavity  complete  in  any  horizontal 
pelvic  plane  ? 

No;  for  example,  the  movable  coccyx  is  opposite  the  pubic 
symphysis,  and  thus  at  all  points  of  the  cavity  there  is  motion, 
protecting  from  pressure  the  fcBtus  and  the  mother. 

Into  how  many  sections  is  the  pelvic  cavity  divided  ? 

Two  ;  an  anterior  and  posterior  inclined  plane. 

What  line  divides  these  planes  ? 

A  line  passing  between  the  ilio-pectineal  eminences  and  the 
spine  of  the  ischium  on  each  side.  The  anterior  plane  is  directed 
downward  and  forward,  while  the  posterior  inclines  toward  the 
sacrum  and  coccyx. 

What  are  the  diameters  of  the  cavity  of  the  pelvis  ? 

An  antero-posterior ;  a  transverse;  and  two  oblique  diameters 
(right  and  left). 

Between  what  points  are  the  diameters  taken  ? 

The  antero-posterior  diameter  extends  from  the  middle  of  the 
pubic  symphysis  to  the  middle  of  a  line  between  the  second  and 
third  sacral  vertebrae,  or,  as  taught  by  some  authorities,  to  the 
centre  of  the  third  sacral  vertebra.  The  transverse  intersects  in 
the  same  plane  the  conjugate  and  oblique  diameters.  The  two 
oblique  diameters  are  measured  from  the  centre  of  each  great 
sciatic  foramen  to  the  centre  of  the  ischio-pubic  foramen  of  the 
opposite  side. 

What  do  the  diameters  measure  1 

Parvin.  Playfair. 

A.  P.,  4|  inches.  5.0  inches. 

T.,        "      "  4.2      " 

O.,       "      " 
The  antero-posterior  measurements  increase  from  above  below, 
while  the  transverse  decrease. 

What  are  some  of  the  other  diameters  of  the  pelvis? 

1.   The  sacro-cotyloid  diameter,  which  extends  from  the  pro- 
montory  to  a  point  immediately  above  the  cotyloid  cavity;    it 


ANATOMY    OF    THE    PELVIS.  23 

measures  from  3.4  to  3.5  inches.  2.  The  sacro-subpubic,  lower,  or 
inclined  conjugate  diameter,  from  the  subpubic  ligament  to  the 
sacro-vertebral  angle.  3.  The  minimum,  useful,  or  obstetrical 
diameter,  beginning  about  two-fifths  of  an  inch  below  the  upper 
border  of  the  symphysis,  and  extending  to  the  promontory.  4. 
The  sacro-pectineal  diameter,  from  the  promontory  to  the  upper 
border  of  the  oblique  ramus  of  the  pubic  bone,  below  the  subpubic 
angle.  5.  The  diagonal  conjugate,  from  the  superior  margin  of  the 
pubes  to  the  centre  of  the  third  sacral  vertebra. 


The  Obliquity,  Planes,  and  Axes  of  the  Pelvis. 

"What  is  meant  by  the  obliquity  of  the  pelvis'? 

The  angle  which  the  pelvis  forms  with  the  spinal  column. 

What  are  the  causes  of  this  obliquity  ? 

First,  the  cartilage  between  the  sacrum  and  the  last  lumbar  ver- 
tebra is  twice  as  thick  in  front  as  it  is  behind ;  second,  the  body 
of  the  fifth  lumbar  vertebra  is  thicker  in  front  than  behind ;  third, 
the  obliquity  of  the  articulating  surface  of  the  first  sacral  vertebra; 
and  fourth,  the  obliquity  of  the  articulation  of  the  innominate 
bones  with  the  sacrum. 

What  angle  does  the  antero-posterior  diameter  of  the  inlet 
make  with  a  horizontal  line  ? 
Nsegele  makes  the  angle  60  degrees,  the  patient  standing. 

What  angle  does   the  diagonal  conjugate  make  with  a 
horizontal  line  ? 

Mayer  makes  the  angle  30  degrees. 

What  angle  does  the  antero-posterior  diameter  make  with 
the  axis  of  the  body  ? 

An  angle  from  130  to  140  degrees. 

What  angle  does  the  antero-posterior  diameter  of  the  outlet 
make  with  a  horizontal  line  ? 
An  angle  from  10  to  11  degrees. 


24  ESSENTIALS    OF    OBSTETRICS. 

Does  the  retrocession  of  the  coccyx  affect  the  size  of  this 
angle  ? 

Yes;  it  changes  with  the  movements  of  the  coccyx  during 
labor. 

What  is  the  height  of  the  sacro-vertehral  angle  above  the 
upper  surface  of  the  pubic  symphysis  ? 

About  3|  inches. 

At  what  point  would  a  line  touch  passing  horizontally 
backward  from  the  upper  margin  of  the  symphysis? 

The  junction  of  the  second  and  third  bones  of  the  coccyx. 

Does  the  pelvic  inclination  remain  in  a  fixed  state  ? 

No ;  it  changes  with  the  different  positions  of  the  body. 

What  do  you  mean  by  the  planes  of  the  pelvis  ? 

Imaginary  surfaces  touching  all  the  points  of  the  circumference 
at  any  portion.  Thus  we  speak  of  the  plane  of  the  inlet  and  out- 
let, and  also  the  planes  of  the  pelvic  cavity.  The  planes  of  the 
cavity  are  not  parallel ;  starting  from  the  posterior  wall  they  con- 
verge and  meet  in  front  of  the  symphysis  pubis. 

What  do  you  mean  by  the  axis  of  the  inlet  and  outlet  ? 

A  line  drawn  perpendicular  to  the  centre  of  their  planes.  If 
the  axis  of  the  inlet  be  continued  upward  it  would  pass  out  at  the 
umbilicus ;  backward  it  would  strike  the  apex  of  the  coccyx,  or  the 
sacro-coccygeal  joint.  The  axis  of  the  outlet  continued  upward, 
intersects  the  axis  of  the  inlet  at  the  centre  of  the  pelvic  cavity, 
and  ends  at  the  promontory ;  if  the  coccyx  be  pushed  backward, 
it  strikes  the  lower  edge  of  the  first  sacral  vertebra.  Continued 
backward  it  passes  out  at  the  perineum  near  the  anus. 

What  do  you  mean  by  the  axis  of  the  cavity  ? 

An  imaginary  curved  line  passing  through  the  pelvic  cavity, 
and  at  all  points  equally  distant  from  the  pubic  symphysis  and  the 
sacrum  and  coccyx ;  it  represents  the  sum  of  the  axes  of  a  series  of 
planes  at  various  levels  of  the  pelvic  cavity. 


ANATOMY    OF    THE    PELVIS.  25 

Is  the  relation  between  the  pelvic  axes  and  the   pelvic 
planes  unchangeable  ? 

Yes. 

Is  the  relation  of  the  planes  and  axes  to  the  body  un- 
changeable ? 

No  ;  for  example,  if  the  subject  is  in  the  erect  position,  the  plane 
of  the  inlet  is  almost  horizontal ;  in  the  recumbent  position,  how- 
ever, the  plane  is  nearly  vertical. 

The  Soft  Parts  of  the  Pelvis. 

What  are  the  functions  of  the  psoas  and  iliacus  muscles  ? 

The  ilio-psoas  muscles,  acting  from  above,  flex  the  thigh  and 
rotate  it  outward ;  from  below,  the  muscles  of  both  sides  pull  the 
spine  and  pelvis  forward.  When  the  body  is  recumbent  they  assist 
in  raising  the  trunk  ;  they  also  uphold  the  erect  position.  The 
iliacus  muscle  serves  as  a  support  to  the  impregnated  uterus,  and 
assists  in  labor. 

What  modifications  are  produced  in  the  bony  pelvis  by  the 
soft  parts  ? 
They  lessen  the  pelvic  diameters ;  the  depth  of  the  iliac  fossse ; 
and  the  obliquity  of  the  iliac  bones.     They  also  change  the  direc- 
tion of  the  pelvic  axis. 

What  pelvic  diameters  are  lessened  ? 

At  the  inlet,  the  transverse  diameter  is  decreased  from  one-half 
to  three-quarters  of  an  inch  by  the  ilio-psoas  muscles  ;  the  oblique 
diameters  one-eighth  of  an  inch,  the  left  oblique  being  still  further 
lessened  by  the  presence  of  the  rectum. 

In  the  cavity  all  the  diameters  are  lessened  from  one-fifth  to 
one-quarter  of  an  inch. 

What  muscles  lessen  the  depth  of  the  iliac  fossae  ? 

The  iliacus  muscles. 

What  muscles  lessen  the  obliquity  of  the  iliac  bones  ? 

The  psoas  muscles. 


26  ESSENTIALS    OF    OBSTETRICS. 

What  changes  are  produced  in  the  direction  of  the  pelvic 
axis  by  the  soft  parts  ? 
A  curved  line  equally  distant  from  the  sacrum  and  the  pubes 
represents  the  axis  of  the  static  pelvis  ;  this,  however,  is  not  true 
of  the  dynamic  pelvis.  The  dynamic  pelvis  presents  a  cavity 
which  is  a  cylindrical  canal,  having  an  anterior  and  a  posterior 
wall,  nearly  vertical.  The  fundus  of  this  cavity  is  at  the  coccyx 
and  its  opening  upon  the  anterior  wall.  The  axis,  therefore,  of 
the  birth-canal  "is  at  first  a  line  directed  backward  and  down- 
ward, and  then  a  line  almost  perpendicular  to  it." 

What  is  the  pelvic  floor  ? 

"  The  pelvic  floor  is  a  thick,  fleshy,  elastic  layer,  dovetailed  all 
round  to  the  bony  pelvic  outlet." 

What  are  the  synonyms  for  the  pelvic  floor  ? 

Pelvic  diaphragm,  inferior  wall  of  the  pelvis,  perineal  wall,  and 
perineum. 

What  organs  perforate  the  pelvic  floor  ? 
The  rectum,  vagina,  and  urethra. 

How  are  these  openings  closed  ? 

The  vagina  and  the  urethra  by  the  apposition  of  their  walls ; 
the  rectum  by  the  contraction  of  its  sphincter. 

What  structures  enter  into  the  formation  of  the  pelvic 
floor? 

The  peritoneum,  subperitoneal  cellular  tissue,  aponeurotic  fasciae, 
muscles,  superficial  fascia,  and  skin. 

What  organs  lie  on  the  outer  or  skin  surface  of  the  pelvic 
floor? 

The  external  organs  of  generation. 

What  organs  lie  on  the  inner  or  peritoneal  surface  ? 
The  uterus  and  its  annexa. 

Describe  the  peritoneum  lining  the  pelvic  floor. 

At  the  symphysis  pubis  the  peritoneum  is  reflected  from  the  an- 
terior abdominal  wall  on  to  the  bladder,  and  passing  over  its  pos- 


ANATOMY    OF    THE    PELVIS.  27 

terior  surface  it  crosses  on  to  the  uterus  at  the  isthmus,  forming  a 
pouch,  called  the  vesico-uterine  cul-de-sac.  It  covers  all  of  the 
anterior  surface  of  the  uterus  above  the  isthmus,  and  passing  over 
the  fundus  it  invests  the  posterior  surface  down  to  the  vaginal 
junction.  From  this  point  it  continues  downward  on  the  posterior 
wall  of  the  vagina  for  about  four-fifths  of  an  inch,  and  is  then  re- 
flected on  to  the  anterior  wall  of  the  rectum ;  the  pouch  formed  at 
this  point  is  called  Douglas's,  or  the  retro-uterine  or  recto-uterine 
cul-de-sac. 

What  is  the  perineum  ? 

That  part  of  the  floor  of  the  pelvis  which  is  bounded,  externally, 
by  the  anus,  the  tuberosities  of  the  ischia,  and  the  vulval  opening; 
internally,  by  the  walls  of  the  rectum  and  vagina. 

What  is  the  length  of  the  perineum  from  the  anus  to  the 
vulval  opening  ? 

In  the  parous  less  than  an  inch,  in  the  nuUiparous  somewhat 
over  an  inch.  During  pregnancy  it  measures  an  inch  and  a  half, 
and  in  labor  it  is  extended  by  the  presenting  part  to  five  inches 
and  a  half. 

Upon  what  does  the  distensibility  of  the    perineum    de- 
pend? 

The  perineal  body. 

What  is  the  perineal  body  ? 

A  mass  of  elastic  and  muscular  tissue,  placed  in  the  centre  of 
the  perineum. 

How  is  the  pelvic  floor  in  its  relations  to  labor  divided  ? 

Into  a  pubic  and  a  sacral  segment. 

Describe  these  segments. 

"  The  pubic  segment  is  made  up  of  loose  tissue,  viz.,  bladder, 
urethra,  anterior  vaginal  wall,  and  bladder-peritoneum.  It  is 
attached  in  front  to  the  symphysis  pubis." 

"  The  sacral  segment  is  attached  to  the  coccyx  and  sacrum  ;  it 
consists  of  rectum,  perineum,  and  strong  tendinous  and  muscular 
tissue." 


28  ESSENTIALS    OF    OBSTETEICS. 

What  effect  has  labor  upon  these  seg^ments  ? 

The  contractions  of  the  uterus  pull  up  the  pubic  segment,  while 
the  sacral  segment  is  pushed  down  by  the  presenting  part. 

In  what  direction  does  the  vagina  pass  through  the  pelvic 
floor? 

Parallel  to  the  antero-posterior  diameter  of  the  inlet. 

The  Female  Generative  Organs.^ 

How  are  the  organs  of  generation  divided  ? 

1st.  Internal,  viz.,  the  uterus  and  its  appendages  (the  ovaries 
and  oviducts) ;  and  the  vagina. 

2d.  External,  viz.,  the  mons  veneris,  labia  majora  and  minora, 
clitoris,  vestibule,  fossa  navicularis,  hymen,  and  fourchette ;  and 
also  the  mammary  glands. 

What  term  is  used  to  include  all  of  the  external  organs  ? 

The  pudendum  or  pudendendum  muliebre.  Vulva  does  not 
include  the  mons  veneris,  although  it  is  occasionally  used  as  a 
synonym. 

What  is  the  reaction  of  the  vaginal  secretions? 
Acid. 

What  is  the  reaction  of  the  glandular  secretions  of  the 
uterus  ? 

Alkaline. 

What  is  the  direction  of  the  current  produced  by  the^Tsilise 
of  the  epithelium  of  the  uterus  ?   .^ 
A:  Toward  the  oviducts.      ^.^^  s»''^5>^^:,,^ 

What  is  the  direction  of  the  current  produced  by  the  cilise 
of  the  oviducts? 

Toward  the  uterus. 

What  are  the  functions  of  the  vagina  ? 

1st.  An  organ  of  copulation. 

1  The  anatomy  of  the  organs  is  to  be  found  in  the  text-books. 


ANATOMY    OF    THE    PELVIS.  29 

2d.  An  excretory  canal  for  the  uterus. 

3d.  An  organ  of  parturition.  ^ 

"What  are  the  functions  of  the  uterus  ? 

1st.  An  organ  of  gestation. 
2d.  An  organ  of  parturition. 

What  is  the  function  of  the  ovary  ? 

Spontaneous  ovulation. 

What  uses  have  the  oviducts  ? 

They  convey  the  spermatozoids  to  the  ovaries,  and  the  ovules 
pass  through  them  to  the  uterus. 

What  is  the  function  of  the  vulvo-vaginal  glands  % 

They  secrete  a  viscid  mucus,  which  lubricates  the  parts  during 
coition. 

What  is  the  vestibule  ? 

It  is  a  triangular-shaped  space;  bounded  at  its  apex  by  the 
clitoris,  on  its  sides  by  the  nymphae,  and  at  its  base  by  the  anterior 
edge  of  the  vaginal  opening.  It  is  of  importance  on  account  of 
the  situation  of  the  meatus  urinarius,  which  is  placed  a  little 
above  the  middle  of  its  base. 

What  methods  are  used  in  the  introduction  of  the  catheter  ? 

It  may  be  introduced  either  by  means  of  sight  or  touch. 

1.  Touch.  Insert  the  index  finger  into  the  vagina,  its  palmar 
surface  looking  upward,  and  make  moderate  pressure  against  the 
anterior  wall  of  the  vagina;  now  pass  the  catheter  along  the  finger 
until  the  opening  of  the  vagina  is  reached,  and  then  by  slightly 
elevating  the  point  of  the  instrument  it  will  pass  into  the  urethra. 

2.  Separate  the  nymphse,  at  the  apex  of  the  vestibule,  with  the 
index  finger,  and  pass  it  down  toward  the  vagina  until  the  meatus 
is  felt  at  its  base ;  the  urethro-vaginal  tubercle  is  an  important 
guide  in  this  method,  as  the  meatus  is  placed  just  above  it. 

Sight.  This  method  of  introduction  is  useful  when  the  parts 
are  swelled  during  labor ;  it  is,  however,  rarely  necessary. 


30  ESSENTIALS    OF    OBSTETRICS. 


EMBRYOLOGY. 

Describe  the  changes  which  take  place  in  the  ovum  after 
impregnation. 

1.  The  germinal  vesicle  immediately  disappears. 

2.  The  union  of  the  male  with  the  female  pronucleus;  the  former 
is  the  head  of  the  spermatozoid,  while  the  latter  is  the  remains  of 
the  germinal  vesicle. 

3.  Cleavage  or  segmentation  of  the  vitellus ;  this  process  con- 
tinues until  it  is  completely  subdivided,  forming  a  mulberry-like 
mass,  called  the  muriform  body. 

4.  The  outer  cells  of  the  muriform  body  arrange  themselves  in 
a  single  layer  beneath  the  vitelline  membrane,  and  enclose  the 
inner  or  smaller  cells.  The  blastopore  is  the  point  at  which  the 
inner  cells  are  not  completely  covered  over. 

5.  Next  the  opening  of  the  blastopore  closes. 

6.  The  blastodermic  vesicle  is  now  formed  by  the  appearance  of 
a  fluid  which  separates  the  inner  and  outer  cells  ;  the  former  col- 
lecting in  a  mass,  and  adhering  to  the  latter  at  a  point  which  was 
originally  the  blastopore. 

7.  A  third  layer  next  appears  between  the  outer  and  inner  layers 
of  cells.  The  blastodermic  vesicle  is  now  composed  of  three  layers, 
viz.,  the  external,  or  epiblast;  the  middle,  or  mesoblast ;  and  the 
internal,  or  hypoblast. 

8.  The  area  germinativa  is  now  developed ;  it  can  be  seen  by 
removing  the  vitelline  membrane  and  exposing  the  epiblast.  It 
is  oval  in  shape ;  its  central  portion  is  light  in  color  (area  pellu- 
cida) ;  and  it  is  surrounded  by  an  opaque  area  (area  opaca). 

9.  Next  there  appears  within  the  area  pellucida  a  groove  or 
furrow  (primitive  groove);  this,  later  on,  becomes  the  spinal  canal. 

10.  Folds  grow  upward  from  the  sides  of  the  primitive  groove 
and  arching  over  unite  with  each  other,  forming  the  spinal  canal ; 
these  folds  are  called  the  dorsal  plates.  Projecting  forward  from 
the  bases  of  these  plates  are  two  folds  (abdominal  plates),  which 
eventually  unite  with  each  other,  and  enclose  the  cavity  of  the 
abdomen. 

11.  In  growing  forward  the  abdominal  plates  divide  the  blasto- 


EMBKYOLOGT.  31 

dermic  vesicle  into  two  parts,  the  external  portion  of  which  is  the 
yelk  sac  (umbilical  vesicle),  while  the  internal  is  embryonic;  the 
vitelline  duct  is  the  canal  between  them.  The  omphalo-mesen- 
teric  artery  and  vein  and  intermediate  capillaries  are  seen  on  the 
surface  of  the  umbilical  vesicle. 

Describe  the  changes  in  the  mucous  membrane   of  the 
uterus  incident  to  pregnancy. 

These  consist  in  the  formation  of  the  deciduous  membranes. 
When  the  ovum  reaches  the  uterus  the  mucous  membrane  "  is 
swelled  and  thrown  into  folds,"  and  it  finds  a  lodgement  in  one  of 
the  spaces  between  these  folds.  That  part  of  the  mucous  mem- 
brane upon  which  the  ovum  rests  is  called  the  placental  decidua, 
or  membrana  serotina ;  the  folds  which  surround  it  is  the  ovular 
decidua,  or  decidua  reflexa  ;  and  all  the  rest  of  the  mucous  mem- 
brane of  the  cavity  of  the  uterus  is  the  uterine  decidua,  or  decidua 
vera.  The  folds,  forming  the  ovular  decidua,  grow,  and  arching 
over  the  ovum,  unite  and  completely  surround  it.  By  the  end  of 
the  third  month  the  ovular  decidua  and  the  uterine  decidua  unite; 
they  then  begin  gradually  to  atrophy  and  separate  from  the 
uterus. 

Describe  the  development  of  the  amnion. 

From  the  sides  of  the  embryo,  and  also  from  its  caudal  and 
cephalic  ends,  the  epiblast  rises  up  into  folds,  which  finally  meet 
and  form  a  complete  sac.  These  folds  consist  of  an  external  and 
internal  layer;  the  former,  or  false  amnion,  unites  with  the  vitelline 
membrane;  while  the  latter,  or  true  amnion,  forms  the  most  internal 
of  the  membranes  covering  the  foetus. 

Describe  the  development  of  the  ailantois. 

During  the  development  of  the  amnion  the  umbilical  vesicle 
begins  to  disappear,  and  the  ailantois  is  seen  springing  from  the 
terminal  portion  of  the  intestine.  At  first  it  is  sausage-like  in 
shape,  but  afterward  it  becomes  spread  out  and  fuses  with  the 
internal  surface  of  the  false  amnion. 

Describe  the  development  of  the  chorion. 

About  the  twelfth  day  the  zona  pellucida  becomes  covered  with 


82  ESSENTIALS    OF    OBSTETKICS. 

small  solid  villi;  it  is  then  called  the  primitive  chorion.  A  little 
later  on  the  permanent  chorion  is  formed  by  the  union  of  the 
primitive  chorion  with  the  false  amnion  and  the  allantois.  The 
vessels  of  the  allantois  penetrate  into  the  villi  of  the  chorion, 
which  now  become  vascular  and  take  on  hypertrophy.  This 
hypertrophy  continues  until  the  third  month  when  all  the  villi 
atrophy,  except  those  attached  to  the  placental  decidua,  which, 
continuing  to  enlarge,  assist  in  the  formation  of  the  placenta. 

The  chorial  villi,  up  to  the  third  month,  are  often  spoken  of  as 
the  "  shaggy  coat." 

How  many  days  does  the  ovum  take  in  passing  through 
the  oviduct  ? 

About  eight  or  ten  days. 

What  is  its  size  when  it  enters  the  uterus  ? 

That  of  a  small  pea. 

What  is  the  function  of  the  allantois  ? 

To  carry  the  allantoic  arteries  to  the  chorion,  thus  assisting  in 
the  development  of  the  placenta. 

What  is  the  function  of  the  chorion  ? 

To  assist  in  the  formation  of  the  placenta. 

What  are  the  fcetal  appendages  ? 

From  without  in :  the  deciduae,  chorion,  and  amnion ;  the  pla- 
centa and  cord  are  also  included. 

What  are  the  uses  of  the  liquor  amnii  ? 

During  pregnancy : 

1.  To  prevent  injury  to  the  contents  of  the  uterus. 

2.  To  assist  in  the  movements  of  the  foetus,  and  also  to  lessen 
their  inconvenience  to  the  mother. 

3.  To  aid  in  the  development  of  the  foetus  and  uterus. 

4.  To  nourish  the  foetus. 
During  labor : 

1.  To  protect  from  pressure  the  foetus  and  cord. 

2.  To  assist  in  the  dilatation  of  the  os  uteri. 

3.  To  lubricate  the  birth-canal. 


EMBRYOLOGY.  33 

Describe  the  development  of  the  placenta. 

It  begins  to  develop  at  the  third  month,  and  is  completely  formed 
by  the  fourth.  The  chorial  villi,  which  are  in  relation  with  the 
placental  decidua,  continuing  to  grow  dip  down  into  the  mucous 
membrane.  Meanwhile  the  placental  decidua  sends  out  villi 
which  interlock  with  those  of  the  chorion,  thus  forming  a  close 
connection  between  the  two.  Blood-sinuses  now  appear  in  the 
maternal  part  of  the  placenta,  into  which  bloodvessels  from  the 
mother  pass  in  and  out ;  the  chorial  villi  float  in  these  sinuses. 

What  is  the  usual  situation  of  the  placenta  ? 

Upon  the  anterior  or  posterior  wall,  near  the  orifice  of  one  of 
the  oviducts. 

What  are  the  functions  of  the  placenta  ? 

1.  Nutrition. 

2.  Eespiration. 

3.  "An  emunctory  for  the  products  of  excretion  in  the  foetus." 

4.  A  glycogenic  function. 

When  does  the  umbilical  cord  begin  to  develop  ? 

At  the  end  of  the  fourth  week. 

From  what  structure  is  the  cord  developed  ? 

The  stalk  of  the  allantois ;  it  has  originally  two  arteries  and  two 
veins. 

What  structures  compose  the  fully  developed  cord  ? 

Wharton's  jelly,  the  umbilical  vein  and  arteries,  and  traces  of 
the  stalk  of  the  allantois  and  umbilical  vesicle ;  these  are  all  in- 
closed in  a  sheath  derived  from  the  amnion. 

To  what  part  of  the  placenta  is  the  cord  usually  attached  ? 

Midway  between  its  centre  and  margin. 

What  is  a  battledore  placenta  ? 

A  placenta  in  which  the  cord  has  a  marginal  attachment. 


34  ESSENTIALS    OF    OBSTETRICS. 

DEVELOPMENT  OF  THE  FEMALE 
GENERATIVE  ORGANS. 

External  Organs. 

What  is  the  cloaca? 

The  terminal  portion  of  the  intestine  after  the  formation  of  the 
vesicle  of  the  allantois ;  it  is  the  opening  common  to  the  allantois, 
the  intestine,  and  the  Wolffian  ducts. 

How  long  does  the  cloaca  remain  ? 

Until  the  middle  of  the  third  month,  when  it  is  divided  by  a 
wall,  thus  forming  the  rectal  and  uro-genital  cavities. 

How  long  does  the  uro-genital  cavity  remain  ? 

Until  some  time  in  the  fourth  month,  when  it  is  divided  into  the 
urethra  and  vagina. 

From  what  is  the  clitoris  developed  ? 

The  genital  tubercle. 

What  is  the  genital  tubercle  ? 

The  genital  swelling  or  tubercle  is  a  prominence  in  front  of  the 
opening  of  the  cloaca. 

From  what  are  the  labia  major  a  developed  ? 

The  genital  folds. 

What  are  the  genital  folds  ? 

Two  folds,  placed  one  on  either  side  of  the  genital  tubercle 
and  the  orifice  of  the  cloaca. 

From  what  are  the  labia  minora  developed  ? 

From  the  sides  of  the  genital  fissure  or  furrow. 

What  is  the  genital  fissure  ? 

A  furrow  extending  from  the  lower  part  of  the  genital  swelling 
to  the  orifice  of  the  cloaca. 


FEMALE    GEN'EKATIVE    ORGANS.  S5 

From  what  is  the  perineum  developed  ? 

From  the  lower  surface  of  the  wall  which  divided  the  cloaca 
into  two  cavities. 

Internal  Organs. 

From  what  are  the  internal  organs  of  generation  devel- 
oped? 

The  Wolffian  bodies. 

What  are  the  Wolffian  bodies  ? 

They  are  two  glandular  bodies  placed  one  on  either  side  of  the 
spinal  column  during  embryonic  life. 

What  is  the  structure  of  a  Wolffian  body  ? 

It  is  composed  of  a  series  of  fine  tubes,  placed  in  a  transverse 
position,  which  empty  into  an  excretory  duct,  known  as  the  Wolf- 
fian duct. 

What  are  the  synonyms  for  the  Wolffian  body  ? 

The  primitive,  false,  or  primordial  kidney;  also  the  kidney  of 
Oken. 

What  is  a  Miiller's  duct  ? 
A  duct  developed  on  the  outer  surface  of  the  Wolffian  body. 

How  many    Mtiller    ducts  are  there  ? 

Two ;  one  for  each  Wolffian  body. 

Describe  their  development. 

They  begin  as  a  layer  of  germinative  epithelium  which  dips 
down  into  the  structure  of  the  outer  surface  of  the  Wolffian  body. 
These  depressions  eventually  become  covered  over,  thus  forming 
two  tubes  or  canals. 

What  organs  are  derived  from  Miiller's  ducts  ? 

The  oviducts,  uterus,  and  vagina. 

Bescribe  their  formation. 

The  ducts  of  Miiller,  passing  forward,  unite  in  the  median  line, 
at  a  point  situated  below  the  round  ligaments.     Above  them  they 


36  ESSENTIALS    OF    OBSTETKICS. 

remain  separated,  forming  the  oviducts,  but  below  the  round  liga- 
ments they  are  in  apposition  with  one  another,  thus  forming  the 
uterus  and  vagina ;  the  fusion  of  the  two  tubes  is  complete  by  the 
eighth  week.  The  extremity  of  each  tube  forms  the  ampulla  or 
pavilion.  The  presence  of  a  secondary  ampulla  is  readily  under- 
stood, by  the  failure  of  the  original  gutter,  from  which  the  tube 
developed,  to  close  completely  over  at  a  given  point.  After  fusion 
has  taken  place  between  the  two  tubes,  below  the  round  ligaments, 
the  intervening  partition  is  absorbed,  thus,  that  which  was  at  first 
a  double  uterus  and  vagina,  now  becomes  two  single  organs. 

Describe  the  development  of  the  ovary. 

An  elongated  mass  of  embryonic  connective  tissue  covered  by 
germinative  epithelium  appears  on  the  inner  surface  of  the  Wolf- 
fian body ;  this  is  the  beginning  of  the  development  of  the  ovary. 
The  stroma  of  the  ovary  is  derived  from  the  connective  tissue 
while  the  ovules  and  ovisacs  are  developed  from  the  epithelium. 
The  primordial  ovules  appear  in  the  epithelium  as  round  cells, 
having  a  nucleus  and  nucleolus.  The  ovisacs  are  developed  from 
the  epithelium,  which  adheres  to  the  ovules  as  they  dip  down  into 
the  structure  of  the  ovary. 

What  is  the  cause  of  anomalies  of  the  uterus  ? 

An  arrest  of  foetal  development. 

What  is  a  uterus  unicornis  ? 

A  one-horned  uterus.  It  is  caused  by  an  incomplete  develop- 
ment of  one  of  Miiller's  ducts ;  generally  there  is  but  one  oviduct. 

What  is  a  uterus  duplex  ? 

It  is  simply  two  uteri,  caused  by  the  failure  of  the  fully  devel- 
oped Miiller's  ducts  to  unite. 

What  is  a  uterus  bicornis  ? 

A  two-horned  uterus.  It  is  caused  by  a  partial  union  between 
the  ducts  of  Miiller — i.  e.,  they  unite,  but  below  the  normal  point. 

What  is  a  uterus  cordiformis  ? 

A  uterus  in  which  there  is  an  incomplete  development  of  the 
fundus;  it  is  depressed,  and  resembles  in  shape  the  heart  of  a* 
playing-card. 


FEMALE    GENEKATIYE    OEGANS.  37 

What  is  a  uterus  septus  bilocularis  ? 

A  uterus  which  has  two  cavities ;  a  double  uterus.  It  is  caused 
by  the  walls  of  Miiller's  ducts  not  being  absorbed.  A  uterus  semi- 
partitus  has  two  uterine  cavities  with  a  single  cervix. 

Will  any  of  these  anomalies  prevent  pregnancy  ? 
No. 

Development  of  the  Embryo  and  Foetus. 

What  do  you  mean  by  the  term  embryo  and  foetus  ? 

The  product  of  conception  is  known  as  an  embryo  up  to  three 
months,  after  which  it  is  called  a  foetus. 

Describe  the  development  of  the  embryo  and  foetus  in  the 

successive  months  of  pregnancy. 
First  Month  : 

Size. — 12th  day  the  ovum  measures  ^th  of  an  inch  ;  15th  day  the 
embryo  is  j^^tb  of  an  inch ;  20th  day  ^th  of  an  inch  ;  21st  day  ith 
of  an  inch ;  and  at  the  end  of  the  month  J  of  an  inch  ;  the  ovum 
being  the  size  of  a  pigeon's  egg. 

Structure. — 12th  day  it  is  composed  of  the  vitelline  membrane 
covered  with  villi,  and  of  the  blastodermic  vesicle ;  loth  day  of 
the  primitive  groove,  amnion,  allantois,  and  the  umbilical  vesicle. 
The  heart  is  also  seen,  a  simple  cavity,  and  commencing  to  beat, 
the  vitelline  circulation  is  established;  the  Wolffian  ducts  also 
begin  to  develop ;  18th  day  the  heart  is  S-shaped ;  20th  day  the 
visceral  arches  and  clefts  are  seen ;  21st  day  the  heart  has  four 
cavities,  and  the  eyes,  ears,  and  mouth  begin  to  develop ;  at  the 
end  of  the  month  rudimentary  limbs  are  seen. 
Secois'd  Month  : 

Size. — The  ovum  is  the  size  of  a  hen's  egg ;  the  embryo  from  1 
to  IJ  inch  in  length,  and  weighs  1  drachm.  The  umbilical  cord 
is  1  inch  in  length. 

Structure. — The  visceral  arches  and  clefts  close ;  hare-lip  and 
cleft-palate  are  impossible  subsequent  to  the  second  month.  The 
eyelids  and  external  ears  are  seen ;  about  the  middle  of  the  month 
the  external  organs  of  generation  begin  to  develop,  and  about  the 


38  ESSENTIALS    OF    OBSTETEICS. 

seventh  week  the  testicles  or  ovaries  are  seen.  The  fingers  and 
toes  are  indicated,  but  they  are  fused  together.  The  umbilical 
vesicle,  reduced  in  size,  hangs  from  the  embryo  by  a  narrow  stalk. 
Third  Month  : 

Size. — The  ovum  is  as  large  as  a  goose's  egg;  the  foetus  is  from 
3  to  3  J  inches  long,  and  weighs  from  5  drachms  to  1  ounce.  The 
umbilical  cord  is  2\  inches  long,  and  begins  to  assume  a  spiral 
form. 

Structure. — The  placenta  is  fully  developed  by  the  end  of  the 
month.  The  fingers  and  toes  are  separated,  and  membrane-like 
nails  appear.  The  eyes  are  closer  together  and  the  ears  well  de- 
veloped. Spina-bifida  is  seldom  anterior,  and  more  often  lumbar 
than  dorsal  or  cervical.  This  is  accounted  for  by  the  fact  that 
ossification  takes  place  last  in  the  lumbar  vertebrae  and  that  the 
bodies  are  the  first  portion  to  become  ossified. 
Fourth  Month  : 

Size. — Length,  4  to  7  i aches;  weight,  4  ounces.  The  cord  meas- 
ures TJ  inches,  and  the  gelatine  of  Wharton  is  formed. 

Structure. — The  external  organs  of  generation  are  developed,  and 
the  sex  can  be  distinguished  by  the  middle  of  the  month.  Lanugo 
(soft  fine  hair)  is  seen  on  the  body,  and  hair  begins  to  develop  on 
the  scalp.     Slight  movements  of  the  extremities  occur. 

Vitality. — If  born  at  the  end  of  the  month,  the  foetus  may  live  a 
few  hours. 
Fifth  Month  : 

Size. — Length,  9  to  10  inches;  weight,  10  ounces;  cord  12  inches 
long. 

Structure. — Movements  are  distinct  and  felt  by  the  mother  about 
the  middle  of  the  month.     The  vernix  caseosa  is  seen. 

Vitality. — If  born  at  the  end  of  the  month,  the  foetus  breathes  and 
cries  feebly,  dying  in  a  few  hours. 
Sixth  Month  : 

Size. — Length,  11  to  13  inches;  weight  1  pound. 

Vitality. — If  born,  the  foetus  lives  from  1  to  15  days. 
Seventh  Month : 

Size. — Length,  13  to  15  inches ;  weight,  3  to  4  pounds. 

Structure. — The  testicles  are  felt  near  the  scrotum,  and  the  nails 
are  almost  completely  developed. 


PHYSIOLOGY    OF    THE    FCETUS.  89 

Vitality. — The  foetus  is  viable.     The  artificial  feeding  of  prema- 
ture children  by  means  of  a  stomach  tube  (gavage)  places  the 
period  of  viability  much  earlier. 
Eighth  Month  : 

Size. — Length,  16  to  17  inches ;  weight,  4  to  5  pounds. 
Ninth  Month  (foetus  at  term) : 

Length,  19^  to  22  inches;  weight,  6  to  7  pounds.  The  body 
is  plump ;  the  lanugo  has  nearly  disappeared ;  the  nails  of  the 
fingers  and  toes  are  hard,  the  former  projecting  beyond  the  finger- 
tips ;  the  testicles  have  descended  into  the  scrotum,  and  the  labia 
majora  are  in  apposition ;  the  hair  on  the  scalp  is  1  to  2  inches 
long;  the  vernix  caseosa  is  found  chiefly  on  the  back  and  flexor 
surfaces  of  the  joints.  The  child  cries  lustily  and  nurses  vigor- 
ously ;  in  the  course  of  a  few  hours  it  passes  urine  and  meconium. 


PHYSIOLOGY  OF  TEE  FCETUS. 

"What  are  the  functions  of  the  foetus  ? 

Nutrition,  circulation,  respiration,  secretion,  and  innervation. 

How  are  the  embryo  and  foetus  nourished  ? 

During  the  passage  of  the  impregnated  ovum  through  the  ovi- 
duct it  is  nourished  first  by  the  discus  proligerus,  and  later  by  an 
albuminous  substance  or  a  "  special  liquid "  derived  from  the 
mucous  membrane  of  the  oviduct.  After  it  reaches  the  uterus 
it  receives  nourishment  from  the  villi  of  the  chorion  and  a  liquid 
secretion  from  the  uterine  mucous  membrane ;  later  from  the  um- 
bilical vesicle,  the  nutritive  materials  of  which  are  carried  to 
the  embryo  through  the  omphalo-mesenteric  veins.  After  the 
formation  of  the  allantois  the  umbilical  vesicle  atrophies,  and  the 
villi  of  the  chorion,  especially  those  in  relation  with  the  placental 
decidua,  furnish  its  nutritive  supply ;  the  liquor  amnii  also  adding 
a  small  amount  of  nourishment.  Finally  the  placenta  is  the  chief 
source  of  nourishment. 

Describe  the  different  circulations  of  intra-uterine  life. 
First.  The  vitelline,  blastodermic,  or  umbilical  circulation. 


40  ESSENTIALS    OF    OBSTETRICS. 

This  circulation  depends  upon  the  umbilical  vesicle.  The  heart, 
at  this  period  of  embryonic  life,  consists  of  a  single  cavity.  At  its 
upper  end  are  given  off  the  first  aortic  arches  ;  at  its  lower,  the 
omphalo-mesenteric  veins.  The  blood  propelled  from  the  heart 
passes  into  the  body  of  the  embryo  through  the  aortic  arches,  and 
is  then  distributed  to  the  vascular  area  of  the  umbilical  vesicle  by 
the  omphalo-mesenteric  arteries ;  from  the  venous  sinus  of  the 
area  it  is  returned  to  the  heart  by  the  omphalo-mesenteric  veins. 

Second.  The  foetal,  allantoid,  or  placental  circulation. 

To  understand  this  subject  properly  it  is  necessary  to  study  the 
structures  peculiar  to  the  circulatory  apparatus  of  the  foetus,  viz., 
1st,  the  ductus  venosus,  connecting  the  umbilical  vein  with  the  in- 
ferior vena  cava ;  2d,  the  Eustachian  valve,  placed  at  the  entrance 
of  the  inferior  vena  cava  into  the  right  auricle ;  it  turns  the  blood 
into  the  foramen  ovale ;  3d,  the  foramen  ovale,  a  large  opening  in 
the  septum  between  the  auricles ;  and,  4th,  the  ductus  arteriosus, 
connecting  the  pulmonary  artery  with  the  aorta;  it  enters  the 
latter  somewhat  below  the  point  at  which  the  arteries  of  the  head 
and  upper  extremities  are  given  off. 

The  blood  from  the  placenta,  rich  with  nutritive  material 
and  oxygen,  is  carried  to  the  foetus  by  the  umbilical  vein ;  after 
entering  at  the  umbilicus  the  blood  is  divided  into  two  currents. 
The  larger  current  passes  into  the  inferior  vena  cava  through 
the  ductus  venosus,  while  the  smaller  one  entering  the  liver  is 
carried  to  the  vena  cava  by  the  hepatic  veins.  The  blood  in  the 
inferior  cava,  composed  chiefly  of  pure  blood  from  the  placenta, 
goes  to  the  right  auricle,  but  the  Eustachian  valve  turns  the  cur- 
rent through  the  foramen  ovale  into  the  left  auricle,  from  which 
it  passes  into  the  left  ventricle.  The  blood  from  the  head  and 
upper  extremities  passes  into  the  right  auricle  through  the  superior 
vena  cava,  from  which  it  enters  the  right  ventricle. 

The  heart  contracting  sends  the  blood  from  the  left  ventricle 
into  the  aorta,  and  from  the  right  ventricle  into  the  pulmonary 
artery.  The  blood  from  the  left  ventricle  supplies  the  head  and 
upper  extremities ;  that  which  enters  the  pulmonary  artery  from 
the  right  ventricle  passes  into  the  aorta  through  the  ductus  arteri- 
osus, somewhat  below  the  point  at  which  the  arteries  of  the  head 
and  upper  extremities  are  given  off.    The  impure  blood  from  the 


PHYSIOLOGY    OF    THE    FCETUS.  41 

right  ventricle  after  entering  the  aorta  supplies  the  trunk,  lower 
extremities,  and  placenta ;  passing  from  the  aorta  into  the  internal 
iliacs,  it  enters  the  hypogastric  arteries  and  thus  is  returned  to  the 
placenta. 

What  organ  receives  the  purest  blood  ? 
The  liver. 

What  changes  take  place  in  the  circulatory  apparatus 
after  birth? 

1.  The  ductus  arteriosus  begins  immediately  to  contract  after 
respiration  is  established,  and  is  completely  closed  in  from  two  to 
ten  days ;  it  degenerates  into  a  cord  connecting  the  left  pulmonary 
artery  to  the  arch  of  the  aorta. 

2.  The  foramen  ovale  is  closed  by  the  tenth  day ;  occasionally 
it  remains  permanently  open,  giving  rise  to  a  condition  known  as 
cyanosis  neonatorum. 

3.  A  portion  of  the  hypogastric  arteries  remain  pervious  and 
are  known  as  the  superior  vesical  arteries. 

4.  The  umbilical  veins  and  ductus  venosus  are  obliterated  in 
from  two  to  five  days ;  the  former  becoming  the  round  ligament 
of  the  liver. 

What  is  the  respiratory  organ  of  the  foetus  ? 

The  placenta. 

What  are  the  proofs  of  this  ? 

1.  The  abundance  of  haemoglobin  found  in  the  blood. 

2.  The  difference  in  color  of  the  blood  in  the  umbilical  vein  and 
arteries. 

3.  The  temporary  interruption  in  the  placental  circulation  causes 
the  blood  in  the  umbilical  vein  to  become  dark. 

4.  Complete  and  permanent  arrest  of  the  placental  circulation 
causes  death  by  asphyxia. 

5.  Pulmonary  respiration  is  the  only  substitute  for  placental. 

6.  Oxygen  has  been  found  in  the  foetal  blood  by  spectroscopic 
examination. 


42  ESSENTIALS    OF    OBSTETRICS. 

Describe  the  secretory  organs  of  the  foetus  ? 

1.  The  skin.  The  sebaceous  glands  begin  to  develop  a  short 
time  before  the  fifth  month,  and  their  secretion  is  seen  about  two 
weeks  later ;  it  becomes  abundant  during  the  sixth  month.  The 
vernix  caseosa,  seen  during  the  latter  part  of  the  fifth  month,  is 
composed  largely  of  epidermic  scales  and  fat  globules ;  sebaceous 
matter  also  enters  into  its  formation.  The  vernix  caseosa  prevents 
osmosis  from  the  foetal  bloodvessels.  The  sudoriparous  glands, 
developing  later  than  the  sebaceous,  do  not  secrete  during  foetal 
life. 

2.  The  serous  membranes.  Hydrocephalus,  hydrothorax,  and 
ascites  prove  that  these  membranes  secrete  during  intra-uterine 
life. 

3.  The  intestinal  mucous  membrane,  liver,  and  pancreas.  The 
liver  is  developed  about  the  fifth  month,  and  forms  bile,  which 
passes  into  the  small  and  large  intestines.  Meconium  is  a  tena- 
cious, odorless,  greenish,  or  black  substance,  consisting  of  the 
secretions  of  the  liver,  pancreas,  and  intestinal  mucous  membrane; 
it  may  also  contain  materials  derived  from  the  liquor  amnii. 

4.  The  kidneys.  These  organs  secrete  during  the  latter  half  of 
intra-uterine  life,  and  it  is  probable  that  the  foetus  voids  its  urine 
into  the  liquor  amnii. 

What  is  known  as  to  the  movements  and  sensations  of  the 
foetus  ?  • 

The  movements  of  the  foetus  are  recognized  by  the  mother  at 
about  four  months  and  a  half.  It  probably  moves  its  upper  and 
lower  extremities  as  early  as  the  sixteenth  or  even  the  twelfth 
week.  As  to  whether  foetal  movements  are  reflex  or  voluntary  is 
still  a  question  of  doubt. 

It  is  impossible  for  the  foetus  to  see,  hear,  or  smell.  Taste  is  the 
earliest  sense  developed,  and  has  been  shown  to  exist  in  a  child 
born  at  seven  months. 


THE    FCETAL    HEAD    AND    TEUNK.  43 

The  Foetal  Head  and  Trunk, 

The  Foetal  Head. 

How  is  the  foetal  head  divided  ? 

Into  the  face  and  cranium. 

How  is  the  cranium  divided  ? 

Into  the  vault  and  base  of  the  skull ;  the  former  is  compressible, 
while  the  latter  is  incompressible. 

What  are  the  peculiarities  of  the  hones  of  the  cranium  ? 

1.  They  are  loosely  united  by  membrane  or  cartilage. 

2.  They  are  flexible  on  account  of  incomplete  ossification. 

3.  The  mobility  of  the  squamous  portion  of  the  occipital  bone, 
which  is  united  to  the  basilar  portion  by  cartilage. 

Name  the  sutures  of  the  fcetal  head. 

The  sagittal,  fronto-parietal,  and  occipito-parietal. 

The  sagittal  suture  extends  from  the  root  of  the  nose  to  the 
superior  angle  of  the  occipital  bone ;  that  portion  situated  between 
the  two  frontal  bones  is  often  spoken  of  as  the  frontal  suture. 

The  fronto-parietal  separates  the  frontal  and  parietal  bones ;  it 
is  also  called  the  coronal  suture. 

The  occipito-|)arietal,  or  lambdoidal  suture  is  placed  between  the 
occipital  and  parietal  bones. 

What  are  the  fontanelles  ? 

Membranous  spaces  formed  by  the  intersection  of  th€  sutures. 

Name  them. 

The  anterior  and  the  posterior  fontanelles.  The  former  is  also 
called  the  bregma;  it  is  large  and  quadrangular  in  shape,  and  is 
formed  by  the  intersection  of  the  sagittal  and  fronto-parietal 
sutures ;  is  easily  recognized  in  labor.  The  latter  is  triangular  in 
shape,  and  formed  by  the  junction  of  the  sagittal  with  the  occipito- 
parietal suture.  It  is  obliterated  in  labor  by  the  overriding  of  the 
bones. 


44  ESSENTIALS    OF    OBSTETKIOS. 

How  are  the  diameters  of  the  foetal  head  classified  ? 

Into  the  antero-posterior ;  the  transverse;  and  the  vertical 
diameter. 

Name  them. 

The  antero-posterior  are  :  the  maximum ;  the  occipito-mental ; 
the  occipito-frontal ;  and  the  suboccipito-bregmatic. 

The  transverse  are  :  the  biparietal ;  bitemporal ;  and  the  bimas- 
toid. 

The  vertical  are  :  the  fronto-mental  and  the  trachelo-  or  cervico- 
or  laryngo-bregmatic. 

Between  what  two  points  are  the  diameters  taken  and 
what  do  they  measure  ? 

Maximum,  from  the  chin  to  a  point  in  the  sagittal  suture  mid- 
way between  the  two  fontanelles. 

Occipito-mental,  from  the  superior  angle  of  the  occiput  to  the 
chin. 

Occipito-frontal,  from  the  superior  angle  of  the  occiput  to  the 
root  of  the  nose. 

Sub-occipito-bregmatic,  from  the  union  of  the  occiput  with  the 
■neck  to  the  middle  of  the  bregma. 

Biparietal,  between  the  parietal  bosses. 

Bitemporal,  between  the  extremities  of  the  fronto-parietal 
suture. 

Bimastoid,  between  the  mastoid  processes. 

Fronto-mental,  between  the  top  of  the  forehead  and  the  chin. 

Trachelo-bregmatic,  from  the  middle  of  the  bregma  to  the  neck 
near  the  larynx. 


Maximum  . 

5Jin. 

Bitemporal 

3.15  in, 

Occipito-mental 

5iin. 

Bimastoid 

2f     in 

Occipito-frontal . 

4|in. 

Fronto-mental  . 

3.15  in, 

Suboccipito-bregmatic 

3|in. 

Trachelo-bregmatic  . 

3f     in 

Biparietal  . 

3|in. 

What  does  the  great  circumference  of  the  foetal   head 
measure  ? 

Fourteen  and  one-half  inches. 


THE    FCETAL    HEAD    AND    TKUNK.  45 

What  does  the  small  circumference  measure  ? 

Twelve  and  three-eighths  inches. 

What  alteration  of  diameters  occurs  during  labor  ? 

In  presentations  of  the  vertex : 

1.  Lessening  of  the  O.-M.  and  O.-F.  diameters. 

2.  Lessening  of  the  Sub-O.-B.  and  B.-T.  diameters. 

3.  Slight  lessening  of  the  B.-P.  diameter. 

4.  Increase  of  the  M.  diameter. 

5.  The  B.-M.,  diameter  remains  unaltered. 
In  presentations  of  the  breech  : 

There  is  little  or  no  alteration  of  diameters. 
In  presentation  of  the  face  : 

1.  Increase  of  the  O.-M.  and  O.-F.  diameters. 

2.  Lessening  of  the  F.-M.  and  T.-B.  diameters. 

What  do  you  mean  by  flexion  of  the  head  ? 

A  bending  forward,  the  chin  resting  upon  the  chest. 

What  do  you  mean  by  extension  of  the  head  ? 

A  bending  backward,  the  occiput  coming  in  contact  with  the 
back  of  the  foetus. 

Does  an  extensive  rotation  of  the  head  from  side  injure 

the  cord  or  the  ligaments  ? 

No.     The  face  may  be  turned  directly  posterior  without  any  in- 
jury resulting. 

The  Foetal  Trunk. 

What  are  the  diameters  of  the  trunk  ? 

The  bis- acromial,  the  dorso-sternal,  the  bis-trochanteric,  and  the 
sacro-pubic. 

What  do  they  measure  ? 

Bis-acromial,  4.7  inches ;  it  can  be  compressed  1  inch. 
Dorso-sternal,  3.7  inches. 
Bis-trochanteric,  3.5  inches. 


46  ESSENTIALS    OF    OBSTETRICS. 

Sacro-pubic,  2  inches ;  increased  to  4  inches  by  the  flexion  of 
the  legs  and  thighs  upon  the  abdomen. 
All  of  the  diameters  can  be  more  or  less  compressed. 

The  Attitude  and  Presentation  of  the  Foetus. 

What  is  meant  by  the  attitude  of  the  foetus  ? 

"The  general  form  and  direction  of  the  trunk,  and  the  position 
of  the  limbs  with  reference  to  it"  (Parvin). 

What  are  the  causes  of  its  attitude  ? 

1.  The  continuance  of  its  embryonic  form;  its  first  distinct 
shape  being  that  of  a  curve. 

2.  Pajot's  law  of  accommodation  :  ''  When  a  solid  body  is  con- 
tained in  another,  if  the  container  is  the  seat  of  alternate  move- 
ment and  rest,  if  the  surfaces  are  slippery  and  little  angular,  the 
content  constantly  tends  to  accommodate  its  form  and  dimen- 
sions to  the  form  and  capacity  of  the  container." 

What  is  meant  by  the  presentation  of  the  foetus  ? 

"  That  part  of  the  foetus  which  is  in  relation  with  the  pelvic 
inlet"  (Parvin). 

"That  portion  of  the  foetus  which  occupies  the  lower  segment  of 
the  uterus  "  (Lusk). 

Does  the  foetus  change  its  position  in  utero  ? 

Yes.  Especially  in  multiparse  ;  it  is  common  to  find  transverse 
presentations  changing  into  normal  ones,  but  rare  for  breech  to 
change  into  head  presentations. 

PUBERTY,  NUBILITY,  OVULATION,  MEN- 
STRUATION, AND  MENOPAUSE. 

What  is  puberty  ? 

''  Puberty  is  that  epoch  in  human  life  when  the  individual  first 
becomes  capable  of  reproduction  "  (Parvin). 

At  what  age  does  it  occur  ? 

It  occurs  earlier  in  warm  countries,  later  in  cold  climates.     In 


THE    FOETAL    HEAD    AND    TRUNK.  47 

temperate  climates  it  usually  occurs  between  the  fourteenth  and 
sixteenth  years ;  the  largest  number  occurring  in  the  fifteenth 
year.  It  may  occur  as  early  as  the  tenth  or  eleventh  year,  or  not 
until  the  eighteenth  or  twentieth. 

What  changes  occur  in  the  female  at  puberty  ? 

The  breasts  enlarge,  the  pelvis  widens,  hair  appears  on  the 
mons  veneris  ^nd  labia  majora,  the  body  fills  out,  and  the  char- 
acter changes.  Two  functions  are  now  established,  viz.,  ovulation 
and  menstruation. 

What  is  nubility  ? 

The  period  of  fitness  for  reproduction. 

How  old  should  a  woman  be  to  bear  children  ? 

Twenty  years. 

What  is  ovulation  ? 

"The  maturing  and  rupture  of  ovisacs,  with  the  subsequent 
escape  of  ovules"  (Parvin). 

Is  ovulation  periodical  ? 

No. 

Is  the  discharge  of  an  ovule  periodical  ? 

Yes,  in  all  probability. 

Does  ovulation  occur  during  pregnancy  and  lactation? 

No ;  it  may,  however,  occur  in  rare  cases. 

What  changes  take  place  in  the  ovary  at  the  time  of 
puberty  ? 

A  number  of  the  ovisacs  begin  to  mature,  and  one  of  them,  more 
developed  than  the  rest,  projects  from  the  surface  of  the  ovary; 
becoming  greatly  distended,  it  ruptures  and  the  ovule  escapes. 
The  development  of  the  ovisacs  causes  a  congestion,  and  an 
increase  in  the  vascular  tension  of  the  ovary. 

What  are  the  causes  of  rupture  of  the  ovisac  1 

1.  An  increase  of  its  contents,  due  either  to  the  breaking  down 
of  the  membrana  granulosa,  or  to  a  fluid  secreted  by  it. 

2.  A  hemorrhage  into  the  ovisac. 


48  ESSENTIALS    OF    OBSTETEICS. 

8.  Fatty  degeneration  of  the  wall  of  the  ovisac. 

4.  Contraction  of  the  coat  of  the  ovisac. 

5.  Contraction  of  the  muscular  fibres  of  the  ovary. 

How  is  the  ovule  carried  throug^h  the  oviduct  ? 

1.  The  movements  of  the  cilise. 

2.  The  peristaltic  contractions  of  the  oviducts. 

What  changes  occur  in  the  non-impregnated  ovum  ? 

The  throwing  off  of  polar  cells,  or  globules. 

Describe  this  process. 

The  germinal  vesicle  moves  from  the  centre  to  the  periphery  of 
the  ovule,  and  a  portion  projecting  beyond  it  becomes  constricted 
and  is  thrown  off;  this  is  repeated  several  times. 

What  is  the  corpus  luteum  ? 

The  corpus  luteum,  or  yellow  body,  is  the  result  of  certain 
changes  which  take  place  in  the  ovisac  subsequent  to  its  rupture 
and  the  escape  of  its  contents. 

How  is  the  corpus  luteum  formed  ? 

The  edges  of  the  tear  in  the  wall  of  the  ovisac  become  glued 
together  by  an  exudation.  The  internal  layer  of  the  ovisac  becomes 
hypertrophied,  while  the  external  layer  contracts,  thus  throwing 
the  former  into  folds,  which,  eventually  coming  in  contact,  unite 
and  obliterate  the  sac.  The  hypertrophy  of  the  inner  layer  is  due 
to  the  development  of  cells,  the  granules  which  they  contain  mul- 
tiply and  are  converted  into  globules. 

How  are  the  corpora  lutea  divided  ? 

1.  Corpora  lutea  of  menstruation. 

2.  Corpora  lutea  of  pregnancy. 

What  is  the  history  of  the  corpus  luteum  of  menstruation  ? 

It  reaches  its  greatest  size  in  from  ten  to  thirty  days,  and  then 
takes  on  atrophy ;  by  eight  or  nine  weeks  nothing  remains  but  a 
cicatrix. 

What  is  the  history  of  the  corpus  luteum  of  pregnancy  ? 

It  reaches  its  greatest  size  in  from   thirty  to  forty  days,  and 


THE    FCETAL    HEAD    AND    TRUNK.  49 

remains  without  any  change  until  the  beginning  of  the  fifth  month, 
when  it  slowly  clecreases  in  size  until  the  end  of  pregnancy,  at 
which  time  it  is  two-thirds  its  largest  dimensions ;  one  month  after 
labor  it  is  obliterated. 

What  is  the  value  of  the  corpus  luteum  of  pregnancy  as  a 
sign  of  conception  ? 

Of  very  little  value,  as  its  characteristics  are  not  constant. 

How  is  the  ovule  carried  to  the  oviduct  ? 

It  is  directed  along  the  groove  of  the  tubo-ovarian  ligament  by 
the  cilise  and  also  by  the  current  produced  by  the  cilise  of  the 
ampulla. 

Some  authorities  teach  that  the  fimbriated  extremity  of  the  ovi- 
duct grasps  the  ovary,  and  that  the  ovule  is  shot,  as  it  were,  into 
its  proper  course. 

What  surrounds  the  ovule  as  it  escapes  from  the  ovisac  ? 

The  discus  proligerus;  an  accumulation  of  the  cells  forming  the 
membrana  granulosa. 

What  is  meant  by  external  migration  of  the  ovule  ? 

The  entrance  of  the  ovule  into  the  oviduct  of  the  opposite  side 
from  the  ovary  from  which  it  escaped. 

How  is  this  explained  ? 

By  the  current  produced  by  the  cilise  being  stronger  on  the 
opposite  side ;  in  some  cases  by  an  occlusion  of  the  tube  on  the 
same  side. 

What  is  menstruation  ? 

"A  temporary  and  intermittent  function  of  the  female  organism, 
and  has  for  its  most  obvious  phenomenon  a  discharge  of  blood 
from  the  genital  canal."  (Parvin.) 

How  are  the  phenomena  of  menstruation  divided  ? 

1.  General  phenomena. 

2.  Local  phenomena. 

What  are  the  general  phenomena  ? 

Chilliness  ;  flashes  of  heat ;  pain  in  different  parts  of  the  body ; 


50  ESSENTIALS    OF    OBSTETRICS. 

and,  in  some  cases,  hysteria.  Some  women  are  sleepy,  and  but  few 
care  for  active  exercise.  Among  other  symptoms  which  may  be 
noted  as  occurring  in  some  cases,  are  diarrhoea,  irritability  of  the 
bladder,  a  dark  circle  under  the  eyes,  swelling  and  painful  sensa- 
tions in  the  breasts,  and  a  sense  of  fulness  in  the  head. 

What  are  the  local  phenomena  ? 

The  changes  in  the  ovary  have  already  been  described;  they 
consist  in  the  enlargement  and  congestion  of  the  organ  and  the 
rupturing  of  an  ovisac.  The  uterus  becomes  greatly  congested  and 
increased  in  size ;  the  cervix  becomes  softer  and  violet-colored, 
and  the  external  and  internal  os  are  open.  The  mucous  membrane 
of  the  cavity  is  greatly  congested  and  swollen ;  it  becomes  folded, 
and  the  surface  presents  an  irregular  appearance.  The  glands 
secrete  abundantly.  The  epithelium  loosens  and  is  detached,  and 
the  capillaries,  no  longer  supported,  rupture  and  the  blood  escapes. 
The  oviducts  become  congested,  their  walls  thicken,  and  blood 
sometimes  escapes  into  them.  The  vagina  becomes  of  a  violet  color, 
its  secretion  more  abundant,  and  its  temperature  slightly  elevated. 
The  external  organs  are  swollen,  and  occasionally  there  is  a  pru- 
ritus. 

"What  is  the  source  of  the  hemorrhage  1 

From  the  mucous  membrane  of  the  cavity  of  the  uterus,  and 
also  probably  from  the  oviducts. 

Is  the  entire  mucous  membrane  of  the  uterus  thrown  off 
during  menstruation  ? 

Williams  believes  that  the  mucous  membrane  is  entirely 
removed  down  to  the  muscular  fibres ;  Kundrat  and  Engelmann 
hold  that  only  the  superficial  layer  is  thrown  off;  and  Moricke 
claims  that  none  is  shed  at  a  menstrual  period. 

What  causes  rupture  of  the  capillaries  ? 

1.  Great  distention. 

2.  Fatty  degeneration,  with  removal  of  the  superficial  epithe- 
lium of  the  uterine  cavity. 

What  is  the  character  of  the  flow  ? 

At  first  it  is  pale,  consisting  chiefly  of  mucus,  with  a  slight 


THE    FCETAL    HEAD    AND    TRUNK.  51 

amount  of  blood;  later  it  becomes  bright  red,  and,  finally,  at  the 
close  of  menstruation  it  lessens  in  quantity,  and  becomes  pale 
again.  The  discharge  is  non-coagulable.  This  is  due  to  its  ad- 
mixture with  the  glandular  secretions,  and  also  on  account  of 
being  defibrinated.  It  has  a  peculiar  odor,  and  is  alkaline  in  re- 
action ;  the  odor  is  probably  due  to  retention,  or  to  admixture  with 
the  secretions. 

What  is  the  quantity  of  the  flow  ? 

From  four  to  six  ounces. 

What  is  the  duration  of  the  flow  ? 

Generally  from  three  to  six  days. 

How  often  does  the  flow  recur  ? 

Every  lunar  month,  or  twenty-eight  days. 

Is  it  necessary  for  every  healthy  woman  to  follow  a  certain 
average  as  to  the  quantity^  duration,  or  recurrence 
of  the  flow  ? 

No  ;  "  every  woman  is  a  law  unto  herself."  Cases  are  on  record 
of  women  who  were  in  perfect  health,  menstruating  every  forty- 
eight  days ;  again,  two  cases  where  the  flow  occurred  only  two  or 
three  times  a  year. 

What  causes  influence  the  first  appearance  of  menstrua- 
tion? 

1.  Climate. 

2.  Eace. 

3.  Residence. 

4.  Heredity. 

5.  Genital  sense. 

What  is  the  genital  sense  ? 

''The  greater  or  less  vigor  shown  in  the  development  of 
ovisacs." 

Does  menstruation  occur  during  pregnancy  and  lactation  ? 

No  ;  except  in  rare  cases. 


52  ESSENTIALS    OF    OBSTETKICS. 

What  is  the  connection  between  ovulation  and  menstrua- 
tion? 

Ovulation  is  independent  of  menstruation,  but  menstruation  is 
dependent  upon  ovulation — i.  e.,  the  development  of  many  ovisacs, 
not  the  periodical  rupture  of  one. 

The  reflex  irritation  caused  by  ovulation  produces  congestion  of 
the  organs  of  generation,  which,  continuing,  is  relieved  by  men- 
struation. Thus  we  have  a  condition  of  plethora  followed  by  that 
of  anaemia;  ovarian  irritation  continuing,  hypersemia  again  takes 
place,  to  be  relieved  later  on  by  menstruation. 

"What  is  the  menopause  ? 

''The  end  of  menstrual  life.'* 

When  does  it  occur  ? 

There  is  no  definite  time ;  in  the  majority  of  cases  from  forty- 
five  to  fifty  years  of  age. 

What  effect  has  the  time  of  puberty  upon  the  appearance 
of  the  menopause  ? 

If  puberty  comes  on  early  the  menopause  usually  appears  late, 
while  delayed  puberty  indicates  an  early  end  of  menstrual  life. 

What  are  some  of  the  symptoms  at  the  time  of  the  meno- 
pause ? 

The  menstrual  flow  does  not  stop  suddenly,  but  becoming  irreg- 
ular, and  after  a  time  ceasing,  it  begins  again  after  several  months, 
and,  finally,  later  on  ceases  altogether.  At  this  time  there  are  apt 
to  be  congestions  of  the  head,  lungs,  and  especially  of  the  liver; 
the  breasts  and  abdomen  may  enlarge,  and  the  woman  imagines 
herself  pregnant.  Later  on  atrophy  of  the  external  and  internal 
organs  of  generation  takes  place,  and  the  woman .  loses,  as  it 
were,  her  sex. 

Can  pregnancy  occur  after  the  menopause  ? 

Yes;  as  ovulation  may  continue,  in  some  cases,  for  several 
months  or  years. 

Can  pregnancy  occur  prior  to  menstruation  ? 

Yes ;  as  ovulation  may  begin,  in  some  cases,  before  the  appear- 
ance of  the  menstrual  flow. 


PREGNANCY.  53 

PREGNANCY. 

Conception. 

What  is  conception  ? 

"The  union  of  two  living  elements;  one  male,  the  other  female" 
(Parvin). 

What  are  the  synonyms  for  conception? 

Impregnation,  fecundation,  and  incarnation. 

How  is  pregnancy  divided  ? 

1.  Simple,  or  single  pregnancy.  • 

2.  Multiple  pregnancy. 

3.  Abnormal  pregnancy. 

What  are  the  fecundating  elements  in  the  semen  ? 

The  spermatozoids. 

What  is  their  length  ? 

From  "s^th  to  ^-j^th  of  an  inch. 

Have  they  the  power  of  movement  ? 

Yes ;  they  propel  themselves  by  rapid  movements  of  their  tails. 
Spermatozoids  pass  from  the  orifice  of  the  vagina  to  the  cervix  in 
three  hours. 

How  long  do  they  retain  their  vitality  ? 

Exposed  to  the  air,  they  cease  their  movements  in  twenty-four 
hours ;  in  a  closed  vessel  they  move  for  fifty  to  sixty  hours ;  and 
in  the  human  female  they  have  been  found  alive  eight  days  after 
sexual  intercourse. 

What  agents  destroy  their  vitality  ? 

Placed  under  a  high  temperature  their  movements  cease,  but 
return  again  when  the  temperature  is  reduced  to  98.4°  F.  They 
are  destroyed  by  electricity,  alcohol,  acids,  concentrated  alkaline 
solutions,  and  corrosive  sublimate,  1  to  10,000 ;  cold  also  retards 
their  movements. 


54  ESSENTIALS    OF    OBSTETRICS. 

What  agents  increase  their  vitality  ? 

Warmth,  weak  alkaline  solutions,  the  glandular  secretions  of 
the  uterus,  and  the  menstrual  fluid. 

Where  does  fecundation  occur  ? 

"  In  the  oviduct,  probabably  near  or  in  the  pavilion." 

How  is  the  ascent  of  the  spermatozoids  effected  ? 

During  coition  the  semen  is  deposited  in  the  vagina,  and  the 
spermatozoids  by  their  own  power  of  motion  enter  the  cervical 
canal.  Their  ascent  along  the  cervical  canal  and  through  the 
cavity  of  the  uterus,  is  caused  by  their  own  movements  and  that 
of  the  cilise  of  the  epithelium.  Their  passage  along  the  oviduct 
is  effected  by  th^ir  own  movements,  aided  by  capillary  attraction. 

How  long"  after  coition  before  the  spermatozoids  begin  to 
enter  the  os  uteri? 
In  from  25  to  30  minutes. 

How  long  a  time  intervenes  between  coition  and  fecunda- 
tion? 

In  all  cases  some  hours,  or  it  may  be  several  days. 

How  may  spermatozoids  enter  the  ovule  ? 

Only  one  spermatozoid  enters  the  ovule  in  normal  fecundation. 
According  to  Newport  and  others,  however,  several  enter  and 
mingle  with  the  yelk. 

At  what  time  is  coition  most  likely  to  be  followed  by 
fecundation  ? 

During  the  first  seven  days  after  the  menstrual  flow  ceases ;  the 
first  day  following  menstruation  being  the  most  likely  time. 

Do  the  spermatozoids  not  concerned  in  fecundation  have 
any  influence  upon  future  pregnancies  ? 

There  are  no  positive  proofs  in  answer  to  this  question.  It  is 
supposed,  however,  that  they  modify  in  some  way  the  ovules  con- 
tained in  the  ovaries;  this  is  spoken  of  as  "infection"  of  the 
mother. 


PREGNANCY.  55 

Changes  in  the  Maternal  Organism. 

What  changes   take  place  in  the  blood  and  circulatory- 
apparatus  ? 

1.  Blood:  The  quantity  is  increased  after  the  fourth  month. 
The  following  changes  occur  in  quality,  viz.,  the  water  and  white 
globules  increase,  and  the  red  globules,  iron^  and  albumen  decrease; 
the  fibrin  decreases  up  to  the  sixth  month,  and  then  increases  until 
the  end  of  pregnancy. 

2.  Heart:  Hypertrophy  of  the  left  ventricle  occurs,  which  dis- 
appears after  pregnancy  is  at  an  end.  There  are  increased  arterial 
tension  and  fulness  of  the  veins. 

What  changes  occur  in  the  skin  ? 

1.  Pigment  deposits  :  These  may  occur  upon  the  face,  the  mam- 
mary glands,  the  external  genitals,  and  the  abdominal  wall.  Upon 
the  abdominal  wall  a  line  of  pigment  deposit  is  usually  seen  in  the 
median  line,  extending  from  the  mons  veneris  to  the  umbilicus ; 
in  some  cases  it  extends  to  the  xiphoid  cartilage. 

2.  Strise :  The  cicatrices  of  pregnancy  become  distinct  about  the 
seventh  month.  They  are  usually  found  upon  the  abdomen,  but 
in  some  cases  also  upon  the  thighs,  hips,  and  mammary  glands. 
They  are  reddish  or  bluish  in  color,  and  do  not  disappear  after 
pregnancy,  but  become  white  and  look  like  old  scars. 

What  changes  occur  in  the  umbilicus  ? 

It  is  usually  depressed  for  the  first  two  or  three  months  of  preg- 
nancy ;  at  the  seventh  month  it  is  on  a  level  with  the  surrounding 
skin ;  from  then,  on  to  the  end  of  pregnancy,  there  is  more  or  less 
protrusion. 

What  changes   occur  in  the   external   genitals  and  the 
vagina  1 

Appreciable  changes  do  not  occur  in  these  organs  until  about 
the  fourth  month.  The  external  genitals  become  more  moist ;  the 
labia  majora  and  minora  larger,  more  open  and  resisting ;  and  pig- 
ment deposits  take  place.  The  urinary  meatus  becomes  red  and 
prominent,  and  the  mucous  membrane  of  the  vulvar  canal  assumes 


56  ESSENTIALS    OF    OBSTETRICS. 

a  dark-red  color.  The  vagina  increases  in  length  about  the  fourth 
month,  and  becomes  shorter  again  at  the  end  of  pregnancy,  from 
the  descent  of  the  uterus  and  the  process  of  labor.  It  becomes  a 
violet-red  color,  and  its  papillae  are  enlarged;  its  secretions  also 
become  more  abundant.  The  muscular  tissue  of  the  vagina  hyper- 
trophies, and  a  greater  supply  of  blood  being  sent  to  it  causes  a 
distinct  pulsation  of  the  vaginal  arteries —Osiander's  sign  of  preg- 
nancy. 

What  changes  occur  in  the  uterus  ? 

1.  Uterine  walls : 

a.  Serous  coat :  The  peritoneal  covering  becomes  thickened. 

b.  Muscular  coat :  The  muscular  fibres  increase  greatly  in  size, 
and  "  embryonic  muscle  cells"  develop  into  fully  formed  muscular 
tissue. 

c.  Mucous  coat:  The  changes  in  the  mucous  membrane  have 
already  been  described. 

2.  Uterine  vessels : 

a.  Arteries :  They  increase  not  only  in  volume  and  length,  but 
also  in  number ;  they  remain  tortuous  during  the  whole  period  of 
pregnancy.  The  arteries  suddenly  enlarge  as  they  enter  the  uterus 
and  are  placed  nearer  to  the  peritoneal  than  to  the  mucous  surface, 
except  at  the  site  of  the  placenta. 

c.  Veins :  They  grow  to  a  very  large  size.  In  the  walls  of  the 
uterus  they  form  sinuses,  which  intercommunicate.  All  of  the 
veins  are  without  valves.  Some  have  only  a  single  coat,  which  is 
closely  attached  to  the  muscular  tissue  of  the  uterus.  The  venous 
sinuses  are  very  numerous  near  the  placenta. 

3.  Size :  At  the  end  of  pregnancy  the  uterus  measures,  in  its 
vertical  diameter,  13.6  inches ;  in  its  transverse,  9.36  inches ;  and 
in  its  antero-posterior,  8.9  inches  (Cazeaux).  At  the  end  of 
pregnancy  the  uterus  weighs  from  20  to  24  times  as  great  as  in  the 
virgin. 

4.  Form :  At  first  the  uterus  is  triangular  in  form,  later  it  be- 
comes pyriform,  then  spheroidal,  and  in  the  last  three  months  of 
pregnancy  it  is  ovoidal. 

5.  Position :  During  the  first  few  weeks  of  pregnancy  the  uterus 
is  lower  in  the  pelvis.     About  the  middle  of  the  third  or  the  be- 


PREGNANCY.  57 

o-innins:  of  the  fourth  month  the  fundus  is  above  the  brim  of  the 
inlet.  Toward  the  end  of  the  fourth  month  it  is  about  2  inches 
above  the  pubes.  About  the  fifth  month  it  causes  a  decided  pro- 
jection of  the  hypogastric  region.  At  the  sixth  month  it  is  on  a 
level  with  the  umbilicus,  at  the  seventh  month  two  inches  above, 
and  toward  the  end  of  the  ninth  month  it  is  just  below  the 
xyphoid  cartilage.  In  the  multigravida  the  fundus  does  not 
reach  as  high  as  in  the  primigravida,  owing  to  the  relaxation 
of  the  abdominal  walls  in  the  former  allowing  it  to  project 
forward.  Usually  the  uterus  sinks  into  the  pelvic  cavity  one 
or  two  weeks  before  labor.  This  is  caused  by  the  resistance  of  the 
abdominal  and  uterine  walls.  The  position  of  the  uterus  is  not 
directly  in  the  median  line,  but  there  is  a  right  lateral  obliquity, 
due  to  the  presence  of  the  rectum  on  the  left  side ;  in  addition  to 
this  obliquity  there  is  also  a  left  lateral  rotation,  which  is  depen- 
dent upon  its  embryonic  development. 

6.  Consistency  of  the  walls :  As  the  uterus  increases  in  size  its 
walls  become  soft  and  elastic;  this  alteration  in  consistency  assists 
in  the  accommodation  of  the  foetus  and  prevents  abnormal  presen- 
tations and  positions. 

7.  Properties  of  the  uterus:  Pregnancy  does  not  create  any 
new  property  of  the  uterus,  but  simply  increases  those  properties 
which  are  obscure  or  latent. 

a.  Contractility :  This  property  is  due  to  the  muscular  structure 
of  the  uterus.  It  is  an  alternate  shortening  and  lengthening  of  its 
muscular  fibres.  Upon  this  property  of  the  uterus  depend  the 
painless  contractions  which  occur  during  pregnancy, 

b.  Eetractility :  "  This  is  that  property  of  uterine  tissue  by 
virtue  of  which  the  uterus,  emptied  of  a  part  of  its  contents, 
acquires  a  greater  thickness  of  its  walls,  while  the  volume  and 
capacity  diminish."  In  other  words,  it  is  simply  a  permanent 
shortening  of  the  muscular  fibres  of  the  uterus.  By  virtue  of  this 
property  the  uterine  walls  are  kept  in  direct  contact  with  the 
foetus,  vessels  are  closed  after  the  separation  of  the  placenta,  and 
the  uterus  is  held  in  the  condition  it  assumes  after  labor. 

c.  Irritability,  elasticity,  sensibility  :  All  of  these  properties  are 
more  or  less  increased  during  gestation. 


58  ESSENTIALS    OF    OBSTETRICS. 

8.  Cervix : 

a.  Softening :  This  process  begins  early  in  pregnancy.  In  the 
primigravida  it  advances  slowly,  but  in  the  multigravida  it  is  more 
rapid.  In  the  latter  the  softening  of  the  vaginal  cervix  advances 
as  follows,  viz. :  ''  One-fourth  is  affected  by  it  at  four  months,  one- 
half  at  six,  three-fourths  at  seven,  and  the  remaining  fourth  at 
eight  months."    This  process  always  begins  around  the  external  os. 

b.  Shortening :  This  process  begins  in  the  last  two  weeks  of  preg- 
nancy ;  in  some  cases  not  until  a  few  hours  before  labor.  After 
the  cervix  is  completely  obliterated  pregnancy  is  ended  and  labor 
begins. 

c.  Orifices  and  cavity  : 

Primipara :  The  external  os  uteri  becomes  round  instead  of  a 
transverse  slit.  It  is  closed  until  the  end  of  pregnancy,  unless 
there  have  been  repeated  examinations  made  or  threatened  abor- 
tion has  occurred.  The  cervical  cavity  is  widened,  but  the  in« 
ternal  os  remains  closed  until  the  cervix  is  obliterated. 

Multipara  :  The  external  os  uteri  is  round,  and  hard  projecting 
nodules  are  felt  along  its  borders,  which  are  the  result  of  lacera- 
tions in  former  labors.  The  internal  os  is  readily  touched  by  the 
examining  finger,  but  it  remains  closed  until  labor;  in  some  cases, 
however,  the  finger  may  touch  the  membranes  during  the  last  few 
weeks  of  pregnancy.     The  cavity  of  the  cervix  is  funnel-shaped. 

What  changes  occur  in  the  uterine  appendages  ? 

1.  Broad  ligaments :  They  undergo  hypertrophy  and  assume  a 
vertical  position. 

2.  Round  ligaments:  They  become  greatly  hypertrophied.  On 
account  of  the  great  development  of  the  posterior  wall  of  the 
uterus,  they  are  not  inserted  upon  the  sides,  but  at  the  "  union  of 
the  posterior  four-fifths  and  the  anterior-one-fifth  of  its  lateral 
surfaces." 

3.  Ovaries :  These  organs  increase  in  size  and  assume  a  vertical 
position.  Ovulation  ceases,  and  the  corpus  luteum  undergoes  cer- 
tain changes,  which  have  been  already  described. 

4.  Oviducts :  They  become  hypertrophied,  and  their  epithelium 
loses  its  cilise.     A  yellowish-white  viscid  liquid,  containing  epi- 


PREGNANCY.  59 

thelium  and  fatty  granulations  without  leucocytes,  lias  been  found 
in  the  oviducts  during  pregnancy. 

Describe  the  changes  occurring  in  the  mammary  glands. 

The  mammary  glands  begin  to  enlarge  early,  about  the  begin- 
ning of  the  second  month.  At  the  same  time  there  occurs  a  tingl- 
ing sensation  in  them  and  they  become  more  sensitive.  The 
superficial  veins  become  swollen,  and  if  the  breasts  undergo  con- 
siderable enlargement  striae  appear  about  the  fifth  or  sixth  month. 
About  the  second  or  third  month  the  nipples  become  pigmented, 
enlarged,  and  sensitive.  During  the  last  three  months  colostrum 
can  usually  be  squeezed  from  the  nipples.  The  areola  becomes 
pigmented,  enlarged,  and  swollen  about  the  second  month.  The 
glands  of  Montgomery,  ten  or  twelve  in  number,  become  enlarged  ; 
they  are  considered  to  be  rudimentary  mammary  glands.  The 
secondary  areola  appears  about  the  fifth  or  sixth  month.  It  has  a 
mottled  appearance,  and  in  the  centre  of  each  white  spot  is  seen  a 
small  black  point,  which  is  a  hair  follicle. 

Signs  and  Diagnosis  of  Pregnancy. 

How  are  the  signs  of  pregnancy  classified? 

1st,  the  subjective  signs,  or  those  that  the  patient  tells  us  ;  2d, 
the  objective  signs,  or  those  which  we  can  ascertain  by  our  various 
senses. 

What  are  the  subjective  signs? 

1.  Absence  of  menstruation. 

2.  Nausea  and  vomiting. 

3.  Salivation. 

4.  Nervous  disorders. 

5.  Enlargement  and  tingling  sensations  in  the  breast. 

6.  Irritability  of  the  bladder. 

7.  Leucorrhoea. 

8.  Quickening. 

What  is  the  value  of  the  various  subjective  signs? 

Absence  of  menstruation  :  This  sign  is  of  great  value  in  a  woman 
hitherto  regular.    It  must  be  remembered  that  conception  has  oc- 


60  ESSENTIALS    OF    OBSTETRICS. 

curred  prior  to  the  first  appearance  of  the  menses,  after  the  meno- 
pause, and  also  during  lactation.  The  amenorrhoea  may  be  due  in 
some  cases  to  a  pathological  condition.  In  rare  cases  menstruation 
only  occurs  during  pregnancy.  Finally,  mental  impressions  may 
cause  menstruation  to  cease  for  one  or  two  periods. 

Nausea  and  vomiting :  This  is  a  very  common  symptom  of  preg- 
nancy, usually  beginning  at  the  first  menstrual  suppression ;  it  is 
known  as  the  "morning  sickness."  It  is  of  great  value  as  a  sign, 
if  associated  with  amenorrhoea,  and  if  it  occurs  at  regular  times, 
and  immediately  upon  taking  food,  the  appetite  being  but  little 
interfered  with. 

Salivation :  An  excessive  secretion  from  the  salivary  glands  is 
uncommon ;  it  generally  accompanies  hyperemesis.  "  Cotton 
spitting  "  is  the  popular  term  for  this  sign. 

Nervous  disorders :  These  symptoms  are  of  but  little  value. 
They  are  generally  indicated  by  some  form  of  mental  disturbance, 
or  a  change  in  the  disposition. 

Enlargement  and  tingling  sensations  in  the  breasts:  These 
symptoms  are  present  in  most  women  soon  after  conception. 
They  are  of  but  little  value,  as  they  may  occur  in  the  non-preg- 
nant. These  symptoms  may  also  occur,  in  some  cases,  during 
menstruation. 

Irritability  of  the  bladder :  This  is  a  sign  of  no  value.  It  usu- 
ally occurs  early  in  pregnancy. 

Leucorrhoea :  A  discharge  of  mucus  from  the  vagina  is  of  no  value 
as  a  sign  of  pregnancy,  as  it  is  common  in  the  non-pregnant. 

Quickening :  Foetal  movements  are  first  recognized  by  the 
mother,  in  most  cases,  at  four  and  a  half  months.  Women  may, 
in  rare  cases,  feel  life  as  early  as  the  twelfth  week ;  in  some  cases 
the  foetal  movements  are  absent  throughout  pregnancy.  Flatus  in 
the  intestines  or  contractions  of  the  abdominal  muscles  may  be 
mistaken  for  foetal  movements.  In  some  cases,  women  who  are  not 
pregnant  assert  that  they  feel  foetal  movements,  really  believing 
the  statement  themselves. 

How  are  the  objective  signs  determined? 

By  inspection,  touch,  and  auscultation. 


PREGNANCY.  61 

How  is  pregnancy  diagnosed  by  inspection  ? 

By  examining : 

1st.  The  face  of  the  patient. 

2d.  The  prominence  of  the  abdomen,  the  curve  of  the  spinal 
column,  and  the  position  of  the  shoulders,  the  woman  being  erect. 

3d.   The  abdomen. 

4th.  The  external  genital  organs  and  the  vagina. 

5th.  The  breasts. 

6th.  The  urine  for  kyestine ;  this  sign  is  of  no  value. 

7th.  The  pulse ;  it  remains  the  same  whether  erect,  sitting,  or 
lying  down — Jorissenne's  sign ;  it  is  of  no  value. 

The  changes  occurring  during  pregnancy  in  the  skin  of  the 
abdomen,  in  the  breasts,  the  external  genitals,  and  the  vagina, 
have  already  been  described. 

What  is  the  '^obstetrical  definition  of  touch?" 

"  A  digital  or  manual  examination  of  the  female  internal  and 
external  generative  organs  and  adjacent  parts  for  diagnostic  or 
therapeutic  purposes"  (Parvin). 

How  is  touch  divided  ? 

Into :  1,  vaginal ;  2,  abdominal ;  3,  rectal ;  4,  vesical. 
Abdominal  touch  may  be  combined  with  either  vaginal  or  rec- 
tal ;  it  is  then  known  as  bimanual  touch. 

Define  abdominal  touch? 

"  The  application  of  the  hands  to  the  abdomen  for  the  diagnosis 
of  pregnancy  and  its  durati"on,  to  ascertain  whether  it  be  single  or 
multiple,  the  presentation  and  position  of  the  foetus,  and  for  the 
correction  of  an  unfavorable  presentation"  (Parvin). 

What  signs  of  pregnancy  are  determined  by  touch  ? 

1.  Changes  in  the  vagina. 

2.  Changes  in  the  cervix  and  os  uteri. 

3.  Hegar's  sign. 

4.  Ballottement. 

6.  Size  and  shape  of  the  uterus. 

6.  Intermittent  contractions  of  the  uterus. 

7.  Uterine  fluctuation. 


62  ESSENTIALS    OF    OBSTETRICS. 

8.  Recognition  of  the  foetus. 

9.  Movements  of  the  foetus. 

Describe  these  signs. 

The  changes  occurring  in  the  Vagina,  the  cervix,  and  os  uteri, 
have  already  been  described. 

Hegars  sign. — This  is  a  softening  of  the  body  of  the  uterus 
above  the  utero-sacral  ligaments.     The  examination  is  made  by 
the  abdomino-rectal  touch.     Hegar  considers  this  a  certain  sign. 
Ballottement,  or  re-percussion. 

Varieties. — Internal  (vaginal),  or  external  (abdominal). 

Methods. — Vaginal.  The  woman  either  stands  or  lies  down.  In 
the  former  position,  the  finger  is  placed  in  the  anterior  cul-de-sac; 
in  the  latter,  in  the  posterior  cul-de-sac.  The  finger  is  given  a 
sudden  upward  movement,  while  the  free  hand  is  placed  externally 
over  the  fundus  of  the  uterus. 

Abdominal.  Place  the  woman  on  her  back,  and  apply  the 
hands  on  either  side  of  the  uterus,  and  then  displace  the  foetus 
from  one  side  to  the  other,  or  place  the  patient  on  her  side,  so  that 
the  abdomen  hangs  over  the  edge  of  the  bed,  and  include  the 
uterus  between  the  two  hands,  one  f)laced  above,  the  other  below, 
then  make  a  sudden  upward  movement  with  the  lower  hand. 

Value. — An  almost  certain  sign.  Multiple  pregnancy,  hydram- 
nios,  oligohydramnios,  placenta  praevia,  or  abnormal  presentations, 
may  prevent  ballottement. 

Differential  diagnosis. — Calculus  of  the  bladder,  sharp  ante- 
flexion of  the  uterus,  pedunculated  subperitoneal  fibroid,  and 
multilocular  ovarian  cyst. 

Time. — Recognized  at  about  five  months;   complete  displace- 
ment six  to  seven  months ;  abdominal  at  six  months. 
Size  and  shape  of  the  uterus. 

By  abdomino-vaginal  touch  the  tumor  will  be  found  to  be  con- 
tinuous with  the  cervix,  and  the  body  of  the  uterus  expanded  and 
elastic. 

The  size  of  the  uterus  in  the  successive  months  of  pregnancy  has 
already  been  described. 
Intermittent  contractions  of  the  uterus  {^Braxton  Hicks' s  sign)  : 

Time. — At  the  end  of  the  third  month. 


PEEGNANCY.  63 

Method. — Place  the  hand  on  the  abdomen  with  sufficient  pres- 
sure to  bring  it  into  contact  with  the  uterus.  The  contractions 
occur  every  five  or  ten  minutes,  and  last  from  two  to  five. 

Differential    diagnosis. — Distended    bladder    and   soft    uterine 
fibroids. 
Uterine  fluctuation  : 

Time. — Second  month. 

Method. — Introduce  two  fingers  into  the  anterior  cul-de-sac,  and 
make  counter-press  are  above  the  pubes. 

Value. — Associated  with  amenorrhoea  and  changes  in  the  areola ; 
it  is  a  certain  sign  (Dr.  Rasch.) 
Recognition  of  the  foetus  : 

Time. — At  five  months ;  different  parts  of  the  foetus  at  the  end 
of  the  sixth  or  beginning  of  the  seventh  month. 

Value. — Certain  sign. 
Movements  of  the  foetus  : 

Time. — The  last  of  the  fifth  or  beginning  of  the  ^xth  month. 

Varieties. — General  and  partial.  In  the  former  the  entire  foetus 
moves,  causing  a  change  in  the  shape  of  the  uterus ;  in  the  latter, 
the  head  or  extremities  only,  giving  the  sensation  of  sudden  taps. 

Value. — Certain  sign.  A  feeble  child  or  hydramnios  may  cause 
them  to  be  absent. 

Differential  diagnosis. — Contractions  of  the  abdominal  muscles, 
and  gas  in  the  intestines. 

What  signs  of  pregnancy  are  determined  by  auscultation? 

1.  Foetal  heart  sounds. 

2.  Uterine  souffle. 

3.  Cardiac  souffle. 

4.  Funic  souffle. 

5.  Foetal  shock. 

Describe  these  signs. 

Foetal  heart  sounds  : 

Description. — They  sound  like  the  tic-tac  of  a  watch  heard 
through  a  pillow. 

Time. — Generally  at  five  months  ;  rarely  at  three,  less  rarely  at 
three  and  a  half  months  ;  heard  by  all  experts  at  four  months. 

Situation  of  stethoscope. — Up  to  the  end  of  four  months  it  should 


64-  ESSENTIALS    OF    OBSTETRICS. 

be  placed  over  the  fundus  of  the  uterus;  after  that  period  the 
situation  of  the  stethoscope  depends  upon  the  presentation  and 
position  of  the  foetus. 

Frequency. — From  120  to  160  per  minute  ;  the  average  being  140. 

JRelation  of  frequency  to  sex. — 134  per  minute  is  taken  as  the 
dividing  line ;  "  above  which  the  sex  will  be  female,  and  below 
which  the  sex  will  be  male."  This  is,  of  course,  by  no  means  a 
certainty. 

Value. — Certain  sign ;  the  death  of  the  foetus,  and  other  condi- 
tions, may  cause  the  sounds  to  be  absent  or  inaudible. 

Causes  influencing  distinctness  : 

1.  Size,  and  period  of  the  development  of  the  foetus. 

2.  Position  of  the  foetus. 

3.  Amount  of  liquor  amnii. 

4.  Thickness  of  abdominal  and  uterine  walls. 
Uterine  souffle. 

Origin. — Due  to  the  passage  of  blood  in  the  uterine  arteries. 

Description. — It  is  synchronous  with  the  maternal  pulse.  It 
varies  in  quality  and  intensity,  resembling  somewhat  the  bruit  of 
an  aneurismal  tumor ;  it  is  heard  for  several  days  after  delivery. 

Situation. — It  is  most  frequently  heard  at  the  lower  segment  of 
the  uterus ;  more  distinct  on  the  left  than  on  the  right  side.  At 
times,  it  may  be  heard  over  any  portion  of  the  uterus. 

Time. — From  four  to  five  months. 

Value. — It  is  of  very  little  value  as  a  sign  of  pregnancy.  It  is 
heard  in  uterine  fibroids,  in  enlargements  of  the  uterus  from  any 
cause,  and  in  a  few  ovarian  tumors. 

Cardiac  souffle. — Of  no  value  as  a  sign.  It  is  caused  by  the 
passage  of  blood  through  the  foramen  ovale. 

Funic  souffle. — Of  no  value  as  a  sign.  It  is  caused  by  pressure 
upon  the  umbilical  cord. 

Foetal  shock. — Can  be  heard  about  the  middle  of  pregnancy ;  the 
impression  conveyed  to  the  ear  is  that  of  a  sudden  tap,  followed 
by  a  quick  bruit. 

What  are  the  certain  signs  of  pregnancy  ? 

1.  Foetal  heart  sounds.  2.  Foetal  movements.  3.  The  recogni- 
tion of  the  foetus. 


PREGNANCY. 


65 


Differential  Diagnosis  of  Pregnancy. 

What  conditions  may  be  mistaken  for  pregnancy  ? 

Physometra,  hydrometra,  liaematometra,  uterine  fibriods,  ovarian 
tumors,  ascites,  fat  in  the  belly  wall,  pseudo-cyesis,  tympanitic 
distention  of  the  intestines,  phantom  tumor,  and  congestive  hyper- 
trophy of  the  uterus. 

What  is  the  differential  diagnosis  between  these  conditions 
and  pregnancy  ? 

Fibroid  Tumors. 
Uterus  irregular  in  shape,  hard 

and  resisting. 
Menstruation  present,  irregular 

and  profuse. 
Very  slow  growth. 
Subjective  signs  absent. 
Intermittent  contractions  of  the 

uterus  rare. 
Uterine  souffle  present. 
Dulness  on  percussion. 
Other  objective  signs  absent. 

Ovarian  Tumor. 
Begins  on  one  side. 
Slow  growth. 

Tumor  more  or  less  to  one  side. 
Deteriorated  health. 
Fluctuation  more  or  less  general. 


Menstruation  present. 

Other  subjective  signs  absent. 

Objective  signs  absent. 


Pregnancy 
Uterus  regular  in  shape,  elastic, 

and  yielding. 
Menstruation  absent. 

Eapid  growth. 
Subjective  signs  present. 
Intermittent   contractions    con- 
stant. 
Uterine  souffle  present. 
Dulness  on  percussion. 
Other  objective  signs  present. 

Pregnancy. 

Begins  in  the  median  line. 

Rapid  growth. 

Tumor  in  the  median  line. 

Health  normal. 

No  fluctuation,  except  in  hy- 
dramnios,  when  it  is  confined 
to  the  upper  part  of  the  abdo- 
men. 

Menstruation  absent. 

Other  subjective  signs  present. 

Objective  signs  present. 

Braxton  Hicks's  sign  of  great 
importance. 


66 


ESSENTIALS    OF    OBSTETRICS. 


Ascites. 
Fluctuation  general. 

Percussion  note :  clear  in  tlie 
median  line,  dull  at  the  flanks  ; 
note  changes  with  position  of 
patient. 

Subjective  signs  absent. 

Objective  signs  absent. 

Fat  in  the  Belly  Wall. 
Usually  occurs  between  40  and 

60  years  of  age. 
Abdomen  is  pendulous. 
Fat  may  be  included  between 

the  hands. 
Subjective  signs  absent 
Objective  signs  absent. 

Physometra. 
Small,  and  of  slow  growth. 
Tympanitic  on  percussion. 
Subjective  signs   of  pregnancy 

absent. 
Objective    signs    of   pregnancy 

absent. 

Hydrometra. 
Usually  occurs  after  menopause. 
Small,  and  of  slow  growth. 
Subjective  signs  absent. 
Objective  signs  absent. 

Hcematometra. 

Atresia  of  genital  canal. 

Uterus  hard  and  resisting. 

Periodical  enlargement  at  men- 
strual period. 

Enlargement  associated  with 
pain. 

Subjective  signs  absent. 

Objective  signs  absent. 


Pregnancy. 

Fluctuation  absent,  except  in 
hydramnios. 

Dull  in  the  median  line,  clear  at 
the  flanks;  no  alteration  in 
note  with  change  in  position. 

Subjective  signs  present. 
Objective  signs  present. 

Pregnancy. 
Before  the  menopause. 

Abdomen  firm  and  prominent. 
The  amount  of  fat  is  usually  not 

large. 
Subjective  signs  present. 
Objective  signs  present. 

Pregnancy. 
Large,  and  of  rapid  growth. 
Dull  on  percussion. 
Subjective  signs  present. 

Objective  signs  present. 

Pregnancy. 
Occurs  before  menopause. 
Large,  and  of  rapid  growth. 
Subjective  signs  present. 
Objective  signs  present. 

Pregnancy. 
No  atresia. 

Uterus  elastic  and  yielding. 
Gradual  and  progressive  enlarge- 
ment. 
No  pain. 

Subjective  signs  present. 
Objective  signs  present. 


PREGNANCY.  67 

Phantom  tumors. — Percussion  gives  a  clear  note  over  the  entire 
abdomen,  and  the  subjective  and  objective  signs  are  absent.  The 
administration  of  an  anaesthetic  will  cause  the  tumor  to  disappear. 

Congestive  hypertrophy  of  the  uterus. — This  disease  may  be  mis- 
taken for  an  early  pregnancy,  especially  when  associated  with 
amenorrhosa.  Time  is  the  great  element  in  the  diagnosis ;  pain  and 
tenderness  of  the  uterus  on  pressure  will  also  assist  in  preventing 
an  error. 

Pseudo-cyesis^  false  or  spurious  pregnancy. — This  condition  gener- 
ally occurs  about  the  time  of  the  menopause  in  hysterical  women 
and  also  in  the  unmarried  who  have  subjected  themselves  to  the 
risks  of  pregnancy.  Very  many  of  the  subjective  signs  of  preg- 
nancy are  present.  The  abdomen  may  enlarge,  the  breasts  swell 
and  secrete  milk,  foetal  movements  may  be  felt,  menstruation  may 
be  absent,  the  stomach  may  be  irritable,  and  at  the  end  of  the 
supposed  pregnancy  the  patient  rtiay  go  into  a  spurious  labor  with 
all  of  the  phenomena. 

In  making  a  diagnosis  the  subjective  symptoms  are  of  no  value. 
The  objective  symptoms  will  at  once  clear  up  the  case. 

Tympanitic  distention  of  the  intestines. — A  clear  note  on  percussion 
over  the  entire  abdomen,  with  an  absence  of  all  the  subjective  and 
objective  signs,  renders  a  mistake  in  diagnosis  impossible. 

What  is  the  diagnosis  between  the  first  and  subsequent 
pregnancies  ? 

Primigravida.  Multigravida. 

The  abdomen  is  smooth  and  re-    The  abdomen    is   relaxed  and 
sisting ;  fresh  striae  are  seen.  pendulous ;  old  striae  are  seen 

as  well  as  fresh  ones. 
The  breasts  are  firm  and  promi-     The    breasts    are    relaxed    and 

nent.  hanging. 

The  uterus  is  firm  and  inclines     The  uterus  is  relaxed  and  in- 

but  little  forward.  clines  forward. 

The  cervix  is  conical  and  the  os     The  cervix  is  club-shaped ;  the 
closed.  OS   open ;   there  is  a  distinct 

anterior  and  posterior  lip,  the 
result  of  lacerations. 


68        ESSENTIALS  OF  OBSTETKICS. 

The  vulva  is  closed  and  the  pos-  The  vulva  gaps  and  there  is 
terior  commissure  is  intact.  more  or  less  laceration  of  the 

perineum. 

The  vagina  is  small  and  the  The  vagina  is  large  and  the  rugae 
rugae  distinct.  more  or  less  indistinct. 

What  is  the  diagnosis  of  the  death  of  the  foetus  ? 

1.  Failure,  after  repeated  examinations,  to  recognize  the  foetal 
heart  sounds  and  foetal  movements. 

2.  The  uterus  ceases  to  grow  and  becomes  flabby. 

3.  The  breasts  decrease  in  size  and  become  soft. 

4.  The  patient's  health  deteriorates ;  she  suffers  from  chilly  sen- 
sations and  a  feeling  of  weight  in  the  hypogastrium. 

5.  If  the  head  of  the  fcetus  can  be  felt  through  the  os  uteri,  the 
bones  will  be  found  to  be  loose  and  movable. 

What  is  the  duration  of  pregnancy  ? 

Between  insemination  and  labor  two  hundred  and  seventy-five 
days;  between  the  end  of  menstruation  and  labor  two  hundred 
and  seventy-eight  days.  It  is  impossible  to  know  the  exact  dura- 
tion of  pregnancy,  unless  we  can  ascertain  the  precise  moment  of 
conception. 

How  is  the  date  of  confinement  calculated  ? 

"  Count  nine  calendar  months  from  the  cessation  of  the  flow, 
and  add  five  days ;  or  we  may  add  five  days  to  the  date  when  the 
flow  stopped  and  count  back  three  months."  Quickening  is  not  to 
be  depended  upon  in  predicting  the  date  of  confinement;  it  may, 
however,  in  some  cases  assist  in  making  the  calculation. 

What  is  meant  by  precocious  births  ? 

Births  occurring  before  the  usual  time  of  viability ;  the  children 
being  born  strong  and  continuing  to  live. 

What  is  meant  by  prolonged  pregnancy  ? 

Pregnancy  continued  beyond  the  usual  period ;  the  foetus  being 
born  alive.  The  law  in  this  country  recognizes  as  legitimate  a 
pregnancy  prolonged  up  to  three  hundred  and  seventeen  days. 


PREGNANCY.  69 

What  is  meant  by  missed  labor  ? 

Pregnancy  continued  beyond  the  usual  period ;  the  foetus  being 
dead. 

Multiple  Pregnancy. 

What  are  the  conditions  necessary  for  multiple  pregnan- 
cies ? 

The  ovules  must  come  from  one  or  both  ovaries,  or  two  ovules 
in  one  ovisac ;  an  ovule  may  contain  two  germs,  or  the  germ  may 
divide  into  two  germs. 

What  is  the  frequency  of  multiple  preg-nancies  ? 

Twins,  1  in  90  pregnancies ;  triplets,  1  in  7000 ;  and  quadruplets, 
1  in  370,000.  There  is  no  authentic  case  on  record  of  over  five 
children  at  a  birth. 

What  are  the  causes  of  multiple  pregnancies  ? 

The  great  causes  are  multiparity  and  heredity ;  other  causes  are 
climate,  great  development  of  the  ovaries,  race,  and  stature. 

How  is  super-impregnation  divided  ? 

Into  super-fecundation  and  super-foetation. 

What  is  super-fecundation  ? 

The  successive  fecundation  of  two  or  more  ovules ;  it  is  not 
simultaneous. 

What  is  super-foetation  ? 

After  conception  has  occurred,  and  the  uterus  is  already  occu- 
pied by  the  product  of  conception,  a  second  impregnation  results 
from  a  subsequent  coitus. 

Is  super-foetation  possible  ? 

There  is  no  anatomical  impossibility  against  its  occurrence  prior 
to  the  union  of  the  ovular  and  uterine  deciduse.  There  is,  how- 
ever, but  little  probability  of  its  taking  place. 

Describe  the  foetal  appendages  in  twin  pregnancies. 

If  the  pregnancy  results  from  the  fecundation  of  two  ovules, 
there  is  no  vascular  connection  between  the  placentae.    Each  foetus 


70  ESSENTIALS    OF    OBSTETRICS. 

has  an  independent  chorion  and  amnion,  and,  at  first,  each  has  its 
own  ovular  decidua,  but  later  on  the  intervening  part  is  absorbed, 
so  that  there  is  but  one. 

If  the  pregnancy  results  from  the  fecundation  of  a  single  ovule 
containing  two  germs,  or  a  single  germ  dividing  into  two,  there  is 
a  single  placenta  and  the  bloodvessels  communicate.  There  is 
also  a  single  chorion,  but  each  foetus  has  its  own  amnion ;  in  rare 
cases  there  is  but  one  amnion.  Twins  developed  from  the  same 
ovum  are  always  of  the  same  sex. 

Is  the  weight  of  twins  greater  than  that  of  a  single  foetus  ? 

Yes;  but  each  foetus  weighs  less  than  that  of  children  born 
single. 

What  is  the  course  of  multiple  pregnancies  ? 

Premature  labor  generally  occurs,  due  to  over-distention  of  the 
uterus.  Triplets  rarely  go  to  term,  and  quadruplets  never.  One 
of  the  foetuses  may  die  early,  and  either  be  expelled,  and  preg- 
nancy continue,  or  it  may  be  retained  and  undergo  certain  changes. 

Diagnosis  of  Multiple  Pregnancies. 

How  are  the  signs  divided? 
Into :   1.  Probable  signs.     2.  Certain  signs. 

What  are  the  probable  signs  ? 

1.  Unusual  size  of  the  abdomen  at  a  given  period  of  pregnancy. 

2.  Unusual  shape  of  the  abdomen ;  it  is  bulging  at  the  flanks 
and  flat  in  the  median  line.  In  some  cases  the  abdomen  is  divided 
in  the  median  line  by  a  depression,  or  sulcus. 

3.  The  foetal  movements  are  stronger,  more  frequent,  and  more 
general. 

4.  The  disorders  of  pregnancy  are  exaggerated.  There  is  greater 
fulness  of  the  veins,  and  more  liability  to  oedema  of  the  lower 
extremities;  there  may  also  be  an  cedematous  swelling  imme- 
diately above  the  pubes. 

5.  There  is  more  liability  to  premature  labor. 

How  are  the  certain  signs  determined  ? 
By  touch  and  auscultation. 


PKEGNANCY.  71 

What  signs  are  determined  by  touch  ? 

1.  Ballottement  is  prevented. 

2.  The  uterus  is  tense  and  resisting. 

3.  The  foetal  members  are  felt  in  different  parts  of  the  uterus. 

4.  The  presence  of  two  foetal  heads. 

After  labor  has  begun  the  bag  of  waters  may  be  found  divided, 
by  a  furrow,  into  two  parts. 

What  signs  are  determined  by  auscultation  ? 

The  sounds  of  two  foetal  hearts.  The  sounds  are  without  isoch- 
ronism,  with  the  maximum  of  intensity  at  different  points. 

Diseases  of  Pregnancy. 

Nausea  and  VorQiting- 

What  are  the  causes  ? 

1.  Stretching  of  the  uterus  by  the  growing  ovum. 

2.  Diseases  of  the  cervix. 

3.  Positional  disorders  of  the  uterus. 

What  is  the  treatment  ? 

Nothing  need  be  done  as  long  as  the  food  is  properly  digested, 
and  the  general  condition  of  the  patient  remains  good.  The  symp- 
toms generally  disappear  during  the  fourth  month. 

In  graver  cases  the  treatment  should  be  as  follows,  viz. : 

1.  Hygienic  treatment :  Breakfast  should  be  taken  in  bed  one 
or  two  hours  before  getting  up.  Give  lime-water,  iced  drinks, 
milk,  champagne,  etc.  It  is  advisable  to  send  the  patient  away, 
giving  her  a  change  of  scene,  and  a  rest  from  sexual  intercourse. 
The  diet  should  be  carefully  regulated.  If  taking  solid  food  is 
followed  by  vomiting,  give  light  and  easily  digested  food  at  short 
intervals.  If  the  patient  expresses  a  desire  for  any  special  article 
of  diet  it  should  be  given  to  her. 

2.  Medical  treatment : 

a.  The  bowels  should  be  carefully  regulated. 

b.  The  following  medicines  have  been  recommended :  The  tinc- 
ture of  nux  vomica  given  in  five  to  ten-drop  doses  before  meals ; 


72  ESSENTIALS    OF    OBSTETEICS. 

subnitrate  of  bismuth ;  oxalate  of  cerium,  in  five  to  ten  grain 
doses  ;  Fowler's  solution ;  morphia,  given  hypodermically ;  chloral, 
twenty  to  thirty  grains  per  rectum,  night  and  morning ;  hydro- 
cyanic acid  (dilute),  given  in  three  to  five  drop  doses,  with  an 
effervescing  draught ;  wine  of  ipecacuanha,  in  minim  doses,  given 
every  hour,  or  three  or  four  times  daily ;  salicin,  in  three  to  five 
grain  doses,  three  times  a  day ;  bromide  of  potassium,  combined 
with  chloral ;  carbonic  acid  water ;  creasote  ;  belladonna  and  the 
tincture  of  aconite  root. 

c.  Local  treatment:  If  the  cervix  is  eroded,  apply  a  ten  per 
cent,  solution  of  nitrate  of  silver  every  two  or  three  days  ;  carbolic 
acid  may  also  be  used.  To  relieve  the  irritability  of  the  uterus, 
vaginal  suppositories  of  morphia  are  highly  recommended ;  the 
application  of  belladonna  to  the  cervix  is  also  advised. 

If  the  uterus  is  retroverted,  or  retroflexed,  it  should  be  restored 
and  kept  in  position  by  a  pessary.  If  the  cervix  is  found  inflamed, 
apply  nitrate  of  silver  or  a  tampon  of  glycerine ;  leeches  have  also 
been  used.  In  some  cases  dilatation  of  the  cervical  canal,  either 
by  means  of  the  finger,  or  a  steel  dilator  devised  for  the  purpose, 
will  be  followed  by  remarkable  results. 

d.  Other  remedies:  Hot  water,  frequently  taken  in  small 
amounts ;  faradic  current  applied  to  the  epigastrium  ;  inhalations 
of  oxygen  ;  ice-bag  to  the  cervical  vertebrae  ;  ether  spray  applied 
to  the  epigastrium;  small  pieces  of  ice  sucked  ad  libitum. 

e.  Rectal  alimentation.  This  subject  will  be  considered  under 
the  treatment  of  hyperemesis. 

Hyperemesis. 

What  is  hyperemesis  ? 

*'  Obstinate,  in  coercible,  uncontrollable,  pernicious  vomiting  of 
pregnancy"  (Parvin). 

At  what  period  of  pregnancy  does  it  usually  begin  ? 

The  majority  of  cases  begin  about  the  end  of  the  third  month. 

Into  how  many  stages  are  the  symptoms  divided  ? 

Three  stages. 


PREGNANCY.  78 

Describe  the  symptoms. 

First  Stage.  The  onset  is  seldom  sudden ;  usually  the  vomiting 
passes  gradually  from  the  simple  form  into  the  graver ;  but  this  is 
not  always  the  case.  In  the  beginning  there  is  nothing  charac- 
teristic of  the  disease,  but  later  on  the  nausea  becomes  more  and 
more  constant,  and  the  vomiting  almost  incessant.  The  matter 
vomited  is  composed  of  food  mixed  with  mucus  and  bile,  and,  in 
some  cases,  blood ;  pure  bile  is  sometimes  vomited. 

The  incessant  vomiting  causes  fatigue  and  gastric  pains ;  in 
some  cases  the  vomiting  is  unaccompanied  by  straining.  In  others 
there  are  occasional  remissions,  or  the  rejection  of  food  is  inces- 
sant, and  the  patient  rapidly  becomes  emaciated  and  loses  strength, 
the  expression  becoming  anxious.  Salivation  and  diarrhoea  may 
occur,  still  further  complicating  the  case. 

Second  Stage.  This  stage  is  characterized  by  a  continuous  fever, 
which  becomes  more  and  more  pronounced,  and  by  the  symptoms 
of  the  first  stage  becoming  more  marked.  The  extremities  become 
cold  and  clammy,  the  skin  of  the  face  and  trunk  hot  and  dry,  and 
the  stomach  rejects  everything  taken  into  it.  The  tongue,  throat, 
and  mouth  become  dry,  the  breath  foul,  and  the  thirst  excessive. 
The  urine  is  high  colored  and  scanty,  and  diarrhoea  is  constant. 
There  are  severe  pains  in  the  head,  and  also  over  the  stomach  and 
the  hypochondriac  regions.  There  are  great  emaciation  and  loss 
of  strength,  and  frequent  attacks  of  syncope.  In  very  rare  cases 
remissions  occur. 

Third  Stage.  The  fever  increases,  but  the  vomiting  stops.  The 
pulse  becomes  small  and  thin,  beating  from  120  to  140.  Halluci- 
nations and  delirium  appear,  followed  by  coma. 

What  is  the  duration  of  the  disease  ? 

In  the  majority  of  cases  from  two  to  three  months. 

What  is  the  prog-nosis  ? 

Grave,  especially  in  the  second  stage ;  in  the  third  stage,  death 
almost  inevitably  occurs.  Spontaneous  abortion  or  death  of  the 
foetus  is  favorable. 

What  diseases  may  be  mistaken  for  hyperemesis  ? 

It  is  to  be  distinguished  from  the  vomiting  caused  by  albu- 


74  ESSENTIALS    OF    OBSTETRICS. 

minuria,   tuberculous    meningitis,   and  ulcer  or  cancer  of  the 
stomach. 

How  is  the  treatment  divided  ? 

Into :  1.  Diet  and  hygiene.  2.  Medical.  3.  Surgical.  4.  Ob- 
stetric. 

What  is  the  treatment  ? 

1.  Diet:  If  the  vomiting  is  absolutely  uncontrollable  the  patient 
should  be  supported  entirely  by  rectal  enamas,  and  kept  at  rest 
in  bed. 

The  following  articles  are  recommended  for  rectal  alimentation : 

Beef-tea,  bromide  of  potassium,  tincture  of  opium,  and  brandy 
every  four  hours,  continued  for  two  days.  Then  begin  giving 
food  by  the  stomach ;  using  at  first  milk  and  lime-water.    (Busey.) 

Animal  broths, 

Peptonized  milk. 

Whites  of  eggs  in  water, 

Leube's  pancreatic  meat  emulsion, 

Defibrinated  blood. 

When  there  is  great  thirst,  inject  into  the  rectum  eight  ounces 
of  water  and  the  whites  of  two  eggs,  three  times  a  day  ;  this  should 
be  given  in  addition  to  the  regular  enemas. 

The  quantity  of  an  enema  should  be  from  four  to  six  ounces; 
it  should  be  given  three  or  four  times  a  day  (Lusk). 

After  the  stomach  is  able  to  retain  food,  give  the  following :    . 

Peptonized  milk. 

Meat  balls. 

Pancreatic  solutions  of  meat, 

Effervescing  koumyss, 

Milk  and  lime-water. 

Cocoa  and  milk. 

In  some  cases  it  is  well  to  allow  the  patient  any  article  of  diet 
she  may  specially  desire. 

2.  Medical  treatment:  This  subject  has  already  been  considered 
(nausea  and  vomiting). 

3.  Surgical  treatment:  This  subject  has  already  been  considered 
(nausea  and  vomiting). 

.4.  Obstretric  treatment :  This  consists  in  the  induction  of  abor- 


PREGNANCY.  75 

tion  or  premature  labor.  The  cause  of  death  in  many  cases  of 
hyperemesis  is  due  to  delay  on  the  part  of  the  physician  in  per- 
forming one  or  the  other  of  these  operations ;  neither  operation 
should  be  undertaken,  however,  without  the  advice  of  a  con- 
sultant. 

CEdema.    Varicose  Veins. 

What  is  the  treatment  of  oedema  of  the  lower  limbs  ? 

The  patient  should  lie  down  and  slightly  elevate  the  limbs  ;  all 
constrictions  must  be  removed,  and  the  parts  should  be  bathed 
several  times  a  day  with  cold  water.  If  the  skin  becomes  tense 
and  the  patient  suffers  much  pain,  warm  flannel  should  be  wrapped 
around  the  limbs,  and  diaphoretics  and  tonics  administered. 

What  is  the  treatment  of  oedema  of  the  vulva  ? 

If  the  cedema  is  extensive,  the  parts  should  be  punctured  so  as 
to  allo^  free  drainage ;  this  should  be  done  with  strict  antiseptic 
precaution.  In  cases  where  the  oedema  is  slight,  the  recumbent 
position  and  frequent  applications  of  cold  water  are  found  useful. 

What  is  the  treatment  of   varicose  veins  of  the  lower 
limbs  ? 

The  bowels  should  be  carefully  regulated.  The  patient  should, 
as  often  as  possible,  assume  a  recumbent  position.  An  elastic 
stocking  should  be  worn  or  a  flannel  bandage  applied  ;  care  should 
be  taken  not  to  apply  the  bandage  too  tightly,  as  too  great  com- 
pression may  be  followed  by  abortion  or  premature  labor.  The 
patient  should  be  provided  with  a  compress  and  bandage  and 
shown  how  to  apply  them,  in  case  of  rupture  occurring  in  one  of 
the  veins. 

What  is  the  treatment  of  rupture  of  a  vein  ? 

A  compress  should  be  placed  over  the  point  of  rupture  and  a 
bandage  firmly  applied,  or  a  needle  may  be  carried  below  the 
bleeding  vessel  and  a  figure-of-8  ligature  carried  around  it. 

What  is  a  thrombus  ? 

A  hemorrhage  beneath  the  skin,  due  to  the  rupture  of  a  vessel. 


76  ESSENTIALS    OF    OBSTETRICS. 

How  is  it  treated  ? 

By  rest  and  the  application  of  cold  dressings. 

How  are  varicose  veins  of  the  vulva  treated  ? 

Rest  in  the  recumbent  position,  and  the  use  of  an  abdominal 
bandage  to  support  the  uterus. 

Salivation.    Relaxation  of  the  Pelvic  Joints. 

What  is  the  treatment  of  salivation  ? 

All  forms  of  treatment  are  unreliable  in  this  affection ;  it  usually 
persists  to  the  end  of  pregnancy.  The  following  remedies  are 
recommended : 

Bromide  of  potassium ;  small  doses  of  atropia ;  pilocarpine,  in 
doses  of  one-half  of  a  grain  ;  the  fluid  extract  of  virburnum  pru- 
nifolium ;  counter-irritation  over  the  parotids,  by  means  of  small 
blisters,  or  the  tincture  of  iodine ;  astringent  mouth  washes  of 
tannin,  chlorate  of  potassa,  sulphate  of  zinc,  or  brandy ;  opium 
given  internally;  inhalations  of  turpentine,  or  creasote,  or  dry 
bitter  orange  peel  kept  in  the  mouth.  The  bowels  should  be  kept 
regulated  by  saline  laxatives. 

"A  sudden  suppression  of  the  excessive  secretion  may  be  fol- 
lowed by  serious  consequences"  (Parvin). 

What  are  the  indications  for  treatment  in  relaxation  of 
the  pelvic  articulations  ? 

1.  Rest. 

2.  To  secure  the  immobility  of  the  joints. 

Rest.  The  patient  should  be  kept  in  bed  during  pregnancy ; 
any  efforts  to  walk,  or  take  exercise  are  followed  by  injurious 
results.  After  labor  the  patient  should  remain  in  bed  for  six 
weeks  or  two  months. 

To  secure  immobility  of  the  joints.  When  the  patient  is  allowed 
to  get  out  of  bed  the  articulations  should  be  held  firmly  together 
by  means  of  a  towel,  or  roller  bandage,  or  a  hip-binder  of  strong 
cloth.  If  the  relaxation  is  marked,  the  joints  should  be  supported 
by  a  leather  girdle  (Boyer),  or  a  complete  metallic  girdle  (Martin), 
or  a  plaster-of-Paris  bandage. 


PKEGNANCY.  77 

Diseases  of  the  Organs  of  Generation. 

Pruritus,  Vegetations  of  the  vulva.  Leucorrhoea.  Displace- 
ments of  the  uterus. 

"What  is  pruritus  vulvae  ? 

An  itching  of  the  external  genital  organs. 

What  is  its  etiology  ? 

It  may  be  caused  by  any  irritative  discharge  from  the  vagina, 
due  to  malignant  disease  of  the  uterus,  erosion  of  the  cervix,  cer- 
vical catarrh,  etc.  Diabetes  may  cause  it,  and  also  various  local 
conditions  of  the  vulva,  as  oedema,  eczema,  herpes,  follicular  inflam- 
mation, or  prurigo.  Menstruation  and  pregnancy,  by  producing  a 
congestion  of  the  genitals,  may  produce  a  pruritus.  Generally  in 
pruritus  vulvae,  occurring  during  pregnancy,  there  is  no  visible 
lesion  of  the  parts. 

How  is  pruritus  vulvae  treated  ? 

The  first  indication  is  to  remove,  if  possible,  the  cause. 

Cervical  catarrh  and  erosion :  Apply  nitrate  of  silver  30  or  60 
grains  to  the  ounce,  to  the  cervical  canal  and  the  erosion,  and 
introduce  a  cotton  tampon  saturated  with  tannin  and  glycerine 
(tannin,  3j ;  glycerine,  ^j),  or  acetate  of  lead  5ij  to  glycerine  ^j. 
The  application  to  the  cervix  should  be  made  every  four  or  five 
days;  the  tampon  should  be  introduced  every  night  at  bedtime, 
and  removed  on  getting  up  in  the  morning. 

If  the  pruritus  depends  upon  a  vaginitis,  use  astringent  or  altera- 
tive applications  to  the  vagina;  a  solution  of  corrosive  sublimate, 
1  part  to  2000  ;  nitrate  of  silver,  30  to  60  grains  to  the  ounce ;  sul- 
phate of  zinc,  2  or  3  grains  to  the  ounce ;  or  alum,  4  or  5  grains  to 
the  ounce.  A  boracic  acid  tampon  is  often  followed  by  good  re- 
sults. The  tampon  is  dipped  in  glycerine  and  then  covered  with 
boracic  acid ;  it  should  be  introduced  into  the  vagina  at  night  and 
removed  in  the  morning. 

The  following  is  the  general  treatment  of  pruritus  vulvae : 

The  vagina  should  be  injected  twice  daily  with  a  solution  of 
borax,  or  a  weak  solution  of  carbolic  acid.  It  is  of  the  utmost 
importance  that  all  injections  into  the  vagina  should  be  tepid,  not 


78  ESSENTIALS    OF    OBSTETRICS. 

hot,  and  that  they  should  be  used  without  any  force,  as  pregnancy 
might  be  interrupted.  The  vulva  should  be  painted  over  with  a  solu- 
tion of  nitrate  of  silver  (gr.  x  to  ^j),  or  a  weak  solution  of  carbolic 
acid,  or  borax  may  be  used ;  in  some  cases  the  frequent  applica- 
tion of  hot  or  cold  water  succeeds.  Corrosive  sublimate,  1  part  to 
2000,  muriate  of  cocaine  (4  to  10  per  cent.),  or  a  solution  of  atropia 
are  also  recommended.  Ointments  containing  oxide  of  zinc,  iodo- 
form, or  salicylic  acid,  often  do  good. 

To  secure  rest  at  night  the  administration  of  morphia  or  chloral 
may  be  found  necessary;  the  tincture  of  cannabis  indica,  or  one 
of  the  alkaline  bromides  may  also  be  used  for  this  purpose. 

How  are  vegetations  of  the  vulva  treated? 

No  active  treatment  is  advisable,  unless  they  become  very  large, 
as  they  disappear  at  the  end  of  pregnancy ;  if  removed,  they  are 
very  liable  to  return.  The  surfaces  should  be  kept  apart  and  com- 
presses saturated  in  a  solution  of  carbolic  acid,  or  Labarraque's 
solution,  applied. 

What  is  the  treatment  of  leucorrhoea  ? 

If  the  discharge  be  slight,  use  tepid  astringent  injections  :  alum, 
borax,  sulphate  of  zinc,  carbolic  acid,  chlorate  of  potassium,  or 
common  salt. 

If  the  secretions  are  excessive  and  cause  irritation  of  the  genitals, 
the  use  of  the  cotton  tampon  is  the  best  treatment.  Take  a  dry 
tampon  of  cotton  and  enclose  in  it,  either  boracic  acid,  alum,  or 
the  subnitrate  of  bismuth.  Then  introduce  into  the  vagina  and 
allow  it  to  remain  for  twelve  or  twenty-four  hours ;  after  its  re- 
moval use  a  tepid  astringent  injection.  A  tampon  saturated  with 
glycerine  containing  either  boracic  acid  or  tannin  may  be  used  in 
the  place  of  the  dry  tampon.  A  new  tampon  should  be  introduced 
into  the  vagina  every  day  for  three  or  four  days.  If  the  leucor- 
rhoea be  specific  in  origin,  apply  to  the  vagina,  either  a  solution  of 
corrosive  sublimate,  1  part  to  1000,  or  nitrate  of  silver,  30  to  60 
grains  to  the  ounce. 

What  is  the  indication  for  treatment  in  prolapse  of  the 
uterus  ? 
To  reduce  the  prolapse :  The  patient  should  assume  a  recumbent 


PREGNANCY.  79 

position  as  often  as  possible  and  wear  a  pessary ;  in  most  cases  tlie 
prolapse  is  spontaneously  cured  about  the  fourth  month.  In  cases 
where  a  pessary  cannot  be  worn,  support  the  uterus  with  a  cotton 
tampon.  If  the  uterus  protrudes  externally  and  cannot  be  restored 
to  its  normal  position,  then  a  bandage  must  be  applied  to  support  it. 

A  pessary  may  be  worn  until  the  sixth  month ;  the  best  intru- 
ment  to  use  is  Hodge's  pessary. 

After  labor  the  patient  should  have  a  prolonged  rest  in  bed. 

Are  anterior  displacements  of  the  uterus  considered  of 
importance  during*  pregnancy  ? 

No ;  they  are  seldom  sufficiently  marked  to  be  pathological ;  it 
is  hardly  possible  for  the  uterus  to  become  incarcerated.  In  the 
multigravida  the  uterus  is  always  more  or  less  anteverted,  on  ac- 
count of  the  relaxation  of  the  abdominal  muscles.  If  the  antever- 
sion  is  moderate,  no  symptoms  are  produced ;  but  if  it  is  marked, 
there  are  constipation,  tenesmus,  pains  in  the  lumbar  and  sacral 
region,  and  irritability  of  the  bladder. 

What  is  the  treatment  of  anteversion  ? 

The  bowels  should  be  regulated,  and  the  patient  kept  in  a  recum- 
bent position.  The  uterus  may  be  supported  by  the  open  cup- 
pessary  of  Thomas. 

In  the  latter  months  of  pregnancy  an  abdominal  bandage  must 
be  firmly  applied  to  support  the  uterus. 

Is  retroversion  of  the  uterus  a  frequent  complication  of 
pregnancy  ? 

No ;  it  is  infrequent  in  the  unimpregnated  uterus. 

What  are  the  results  of  retroversion  ? 

1.  It  spontaneously  rises  into  the  abdominal  cavity. 

2.  It  remains  below  the  promontory  of  the  sacrum,  and  the 
cervix  bending  upon  itself,  it  becomes  a  retroflexion. 

What  are  the  results  of  retroflexion  ? 

1.  It  usually  rises  into  the  abdominal  cavity  and  the  pregnancy 
may  continue  to  term. 

2.  Abortion  may  occur,  the  result  of  inflammation  of  the  uterus. 


80  ESSENTIALS    OF    OBSTETRICS. 

3.  The  uterus  may  become  incarcerated  below  the  promontory 
of  the  sacrum. 

What  is  the  treatment  of  retroflexion  ? 

If  the  uterus  is  movable,  it  should  be  replaced  and  a  pessary 
worn  until  the  fourth  month ;  use  the  Albert  Smith  or  Hodge  pes- 
sary. The  bowels  should  be  kept  regular,  and  urine  should  not  be 
allowed  to  accumulate  in  the  bladder ;  there  should  be  no  com- 
pression around  the  abdomen,  and  straining  at  stool  should  be 
avoided.  The  patient  should  assume  the  knee-chest  position  for  a 
few  minutes  every  day,  and  when  lying  in  bed  should  not  be  upon 
her  back,  but  upon  her  side. 

If  the  uterus  is  immovable,  gradual  attempts  to  restore  it  should 
be  made  daily,  as  follows  : 

1.  The  patient  assumes  the  knee-chest  position,  and  the  physi- 
cian introduces  two  fingers,  either  into  the  rectum  or  vagina,  and 
makes  gentle  pressure  upon  the  fundus  of  the  uterus ;  the  uterus 
may  be  gradually  restored  in  about  a  week  or  longer. 

2.  The  "push  and  pull"  method  :  press  the  body  of  the  uterus 
up  with  the  blade  of  a  Sim's  speculum,  and  at  the  same  time  catch 
the  cervix  with  a  tenaculum  and  draw  it  downward  and  backward. 

After  the  uterus  has  been  restored  to  its  normal  position  a 
pessary  should  be  worn. 

What  are  the  symptoms  of  incarceration  ? 

Retention  of  urine,  in  some  cases  associated  with  incontinence; 
difficult  and  painful  defecation  ;  constipation  ;  severe  pains  in  the 
lumbar  and  sacral  regions ;  a  heavy  bearing-down  sensation  in  the 
pelvis ;  and,  in  some  cases,  oedema  of  the  legs  and  arms.  If  the 
incarceration  is  not  relieved,  peritonitis  and  uraemia  follow. 

What  are  the  results  of  incarceration  ? 

1.  Spontaneous  restitution. 

2.  Abortion  and  recovery. 

3.  Cystitis  ;  retention  of  urine. 

4.  Inability  to  empty  the  bowels. 

5.  Death  from : 

a.  Metritis. 

h.  Perforation  of  the  bladder. 


PREGNANCY.  81 

c.  Gangrene  of  the  uterus. 

d.  Uraemia. 

e.  Peritonitis. 

What  are  the  results  of  the  retention  of  urine  ? 

In  six  days  the  mucous  membrane  of  the  bladder  sloughs ;  in 
ten  days  perforation  occurs. 

What  is  the  treatment  of  incarceration  1 

The  indication  is  to  replace  the  uterus.  The  bladder  and  bowels 
should  be  evacuated,  the  former  with  a  catheter ;  if  this  is  found 
to  be  impossible,  then  aspirate  about  three  inches  above  the  pubes. 
In  a  number  of  cases  spontaneous  restitution  occurs  after  the 
bladder  is  emptied ;  if  this  does  not  occur,  then  the  uterus  must 
be  replaced.  If  the  uterus  is  bound  down  by  adhesions  and  cannot 
be  restored,  then  abortion  must  be  induced. 

To  restore  the  uterus  place  the  patient  in  the  knee-chest  position 
and  make  steady  pressure  upon  the  fundus  with  two  fingers  either  in 
the  vagina  or  rectum.  Another  plan  is  the  "push  and  pull "  method 
already  referred  to.  In  cases  requiring  the  use  of  an  anaesthetic, 
place  the  patient  in  Sims'  latero-prone  position  and  make  pressure 
upon  the  fundus  of  the  uterus  by  means  of  four  fingers  introduced 
into  either  the  vagina  or  rectum.  Playfair,  in  cases  of  incarcera- 
tion, advises  the  use  of  a  rubber  bag  introduced  into  the  vagina  and 
filled  with  water ;  the  water  must  be  let  out  every  few  hours  to 
allow  the  woman  to  empty  the  bladder.  Generally  the  uterus  is 
replaced  in  twenty-four  hours  by  this  method. 

After  the  uterus  has  been  replaced,  the  patient  should  wear  a 
pessary ;  a  relapse  is  not  likely  to  occur. 

Diseases  of  the  Ovum. 

Myxomatous  Degeneration  of  the  Placenta,  or  Hydatidiform  Mole. 

What  is  the  morbid  anatomy  ? 

It  is  a  disease  of  the  chorial  villi.  A  great  number  of  cyst-like 
formations  are  found,  varying  in  size  from  a  millet-seed  to  a 
walnut;  the  cysts  are  of  many  different  shapes.  The  investing 
epithelium  of  the  villi  and  their  contents  undergo  hypertrophy 
and  mucoid  degeneration.     The  pedicle  of  a  cyst  contains  the 

6 


82  ESSENTIALS    OF    OBSTETKICS. 

same  tissue  as  Wharton's  jelly  of  tlie  umbilical  cord.  The  cysts 
contain  albumen  and  mucin,  which  resemble  in  appearance  the 
liquor  amnii. 

If  the  disease  occurs  before  the  second  month,  the  degeneration 
involves  the  entire  surface  of  the  chorion,  resulting  in  the  death 
of  the  embryo,  which  undergoes  solution,  leaving  the  amniotic 
cavity  empty ;  the  vessels  of  the  villi  are  obliterated.  If  the  dis- 
ease occurs  after  the  placenta  begins  to  form,  the  degeneration  is 
limited  to  the  placental  part  of  the  chorion ;  although  in  some 
cases  cysts  are  found  in  other  parts.  If  the  degeneration  be  suffi- 
cient to  destroy  the  foetus,  it  becomes  disintegrated  and  is  found 
in  the  amnion  cavity.  If  only  a  portion  of  the  placenta  is  involved, 
the  foetus  may  go  to  term  ;  the  uterus  may  contain,  occasionally, 
a  healthy  foetus  along  with  a  hydatidiform  mole. 

An  hydatidiform  mole  resembles  in  appearance  a  bunch  of 
grapes  or  currants. 

Eetention  of  the  placenta  or  rupture  of  the  uterus  may  occur  in 
this  disease,  caused  by  the  degenerated  villi  penetrating  into  the 
uterine  sinuses. 

What  is  the  etiology  of  hydatidiform  mole  ? 

The  disease  is  less  frequent  in  the  primiparse  than  in  the  multi- 
paree ;  it  is  more  frequent  in  women  of  advanced  age  ;  it  generally 
occurs  during  the  first  months  of  pregnancy,  but  it  cannot  occur 
after  the  latter  part  of  the  third  month. 

The  exciting  causes  of  this  disease  are  as  yet  unsettled.  They 
may  be  maternal  in  origin  or  due  to  disease  of  the  ovum.  In 
proof  of  the  former  theory  may  be  mentioned  the  frequent  recur- 
rence of  the  condition  in  the  same  woman,  and  its  frequent  asso- 
ciation with  uterine  fibroids  and  with  a  cancerous  or  syphilitic 
dyscrasia.  The  probability  of  the  latter  theory  is  supported  by  the 
fact  that  a  healthy  foetus  is  occasionally  found  associated  with  a 
hydatidiform  mole.  Again,  cases  occur  in  which  the  death  of  the 
foetus  cannot  be  accounted  for  by  the  degeneration  of  the  villi  on 
account  of  the  limited  extent  of  the  disease.  Spiegelberg  believes 
the  disease  to  be  due  to  an  abnormal  development  of  the  allantois, 

Bescribe  the  symptoms. 

1.  Eapid  enlargement  of  the  abdomen. 


PKEGNANCY.  83 

2.  Attacks  of  hemorrhage  or  a  muco-sanguinolent  discharge. 

3.  Expulsion  of  vesicles. 

4.  Doughy  feel  of  the  uterus  on  palpation. 

5.  Obscure  fluctuation. 

6.  The  foetal  members  cannot  be  recognized  by  palpation. 

7.  The  lower  segment  of  the  uterus  is  tense. 

8.  Lumbar  and  sacral  pains. 

9.  The  foetal  heart  sounds  cannot  be  heard. 

10.  Ballottement  is  prevented. 

The  diagnosis  is  made  by  the  above  subjective  and  objective 
symptoms ;  the  discharge  of  vesicles  is  the  only  certain  symptom. 

What  is  the  prognosis  ? 

The  patient  rarely  goes  to  term  and  the  foetus  in  nearly  all  cases 
dies.    The  danger  to  the  mother  is  from  hemorrhage. 

What  is  the  treatment  ? 

If  the  hemorrhage  is  slight,  no  active  treatment  is  advised. 
Place  the  patient  at  rest,  and  give  cold  drinks  and  opium. 

If  the  hemorrhage  is  grave,  then  introduce  a  tampon  and  give 
ergot. 

If  the  hemorrhage  returns,  then  the  indication  is  to  dilate  the 
cervical  canal  and  empty  the  uterus. 

The  dilatation  of  the  cervix  may  be  accomplished  by  the  finger, 
or  by  Barnes's  or  Tarnier's  dilator.  The  use  of  tents  increases  the 
dangers  of  septicaemia.  After  the  uterus  is  emptied  of  its  contents, 
wash  out  the  cavity  with  a  warm  solution  of  corrosive  sublimate, 
1  part  to  3000.  If  hemorrhage  occurs,  apply  the  perchloride  of 
iron.  The  after-treatment  consists  of  rest  and  the  administration 
of  ergot.  The  use  of  Thomas's  dull-wire  curette  is  advised  in  cases 
where  there  is  a  persistent  hemorrhage. 

Polyhydramnios. 

What  is  polyhydramnios  ? 

An  excess  in  the  amount  of  liquor  amnii. 

What  is  the  etiology  of  polyhydramnios  ? 

There  are  various  theories,  as  follows : 
1.  Patulous  condition  of  the  vasa  propria. 


84  ESSENTIALS    OF    OBSTETRICS. 

2.  Disease  of  the  foetal  heart,  lungs,  or  liver. 

3.  Increased  activity  of  the  kidneys. 

4.  Changes  in  the  maternal  circulation. 

5.  A  morbid  condition  of  the  decidua,  chorion,  or  amnion. 

6.  Syphilis. 

The  disease  is  more  frequent  in  the  multigravida  than  in  the 
primigravida. 

How  many  forms  of  the  disease  are  described  ? 

Two :  an  acute  and  chronic  form. 

"What  are  the  symptoms  of  polyhydramnios  ? 

1.  Rapid  development  of  the  uterus. 

2.  The  uterine  walls  are  tense  and  elastic. 

3.  Obscure  sense  of  fluctuation. 

4.  Fcetal  heart  sounds  faint  or  absent. 

6.  Foetus  cannot  be  recognized  by  palpation. 

6.  The  cervix  is  high  up  and  more  or  less  shortened. 

7.  The  foetus  moves  from  one  position  to  another  with  great  ease. 

Other  symptoms  are :  dyspnoea,  palpitation  of  the  heart,  irrita- 
bility of  the  stomach,  oedema  of  the  lower  extremities,  and  inguinal, 
lumbar,  sacral,  and  abdominal  pains. 

The  symptoms  occur,  as  a  rule,  about  the  fifth  or  sixth  month  ; 
in  some  cases  earlier.     The  accumulation  of  fluid  is  gradual. 

In  the  acute  form  the  accumulation  of  fluid  may  take  place  in  a 
few  days ;  in  addition  to  the  symptoms  of  the  chronic  form,  fever, 
vomiting,  and  intense  pain,  are  present. 

What  is  the  diagnosis  ? 

The  diagnosis  depends  upon  the  subjective  and  objective  symp- 
toms already  described.  Braxton  Hicks's  sign  is  of  great  value  in 
determining  the  existence  of  pregnancy.  Polyhydramnios  may  be 
mistaken  for  a  multiple  pregnancy. 

What  is  the  prognosis  ? 

Very  grave  for  the  child ;  nearly  one-fourth  die.  The  prognosis 
for  the  mother  is  favorable,  unless  the  disease  is  associated  with  an 
organic  afiection  of  the  heart.  The  danger  of  post-partum  hemor- 
rhage should  not  be  forgotten. 


PREGNANCY.  85 

How  is  the  treatment  divided  ? 

Into  1,  the  expectant  plan ;  2,  the  active  plan. 

The  former  consists  in  the  use  of  an  abdominal  supporter,  and 
refraining  from  active  exercise.  The  latter,  or  active  plan  of 
treatment,  is  indicated  whenever  grave  symptoms  are  present,  due 
to  over-distention,  and  when  there  are  serious  disturbances  of  the 
mother's  heart.  The  indication  is  to  induce  abortion  or  premature 
labor.  The  iqjembranes  should  be  punctured  high  up,  and  in  the 
interval  of  the  pains.  The  hand  should  be  used  as  a  plug  in  the 
vagina  to  prevent  the  rapid  discharge  of  the  liquor  amnii.  If  the 
presentation  is  normal,  leave  the  further  progress  of  the  case 
to  nature;  turning  is  indicated  if  the  foetus  presents  by  the 
shoulders.  Prophylactic  measures  should  be  taken  against  post- 
partum hemorrhage. 

Abortion. 

What  is  abortion  1 

"  Abortion,  or  miscarriage,  is  the  expulsion  of  the  product  of 
conception  before  the  time  that  the  foetus  is  viable"  (Parvin). 

How  is  abortion  divided  ? 

Into  1.  Ovular;  during  first  three  weeks. 

2.  Embryonic ;  up  to  the  fourth  month. 

3.  Foetal ;  subsequent  to  the  fourth  month. 

How  is  abortion  classified  ? 

Into  1.  Spontaneous. 

2.  Artificial ;  subdivided  into 

(a)  Therapeutic. 

(b)  Criminal. 

According  to  some  authorities,  the  term  abortion  is  used  when 
the  ovum  is  expelled  during  the  first  three  months ;  subsequent  to 
the  third  month  up  to  the  time  of  viability,  the  term  miscarriage  is 
employed. 

What  is  meant  by  the  term  incomplete  abortion? 

The  expulsion  of  the  embryo  or  foetus  without  the  membranes 
or  placenta. 


86  ESSENTIALS    OF    OBSTETRICS. 

What  is  meant  by  the  term  missed  abortion  ? 

The  death  of  the  foetus  not  followed,  within  two  weeks,  by  its 
expulsion. 

At  what  period  of  pregnancy  do  abortions  usually  occur  ? 

Spontaneous  abortions  generally  occur  in  the  first  three  months; 
and,  as  a  rule,  at  a  time  corresponding  with  what  would  have  been 
a  monthly  flow.  Criminal  abortions  usually  occur  from  the  third 
to  the  sixth  month. 

How  are  causes  of  abortion  divided  ? 

Into  the  paternal,  maternal,  and  ovular  causes. 

What  are  the  paternal  causes  ? 

1.  Syphilis. 

2.  Alcoholism. 

3.  Exhausting  chronic  diseases. 

4.  Working  in  sulphur. 

5.  Sexual  excesses. 

6.  Old  age  or  extreme  youth. 

7.  Lead  poisoning. 

How  are  the  maternal  causes  divided  ? 

Into  external  and  internal  causes. 

What  are  external  causes  ? 

1.  Violent  exercise. 

2.  Traumatisms ;  accidental  or  intentional. 

3.  Tight  corsets. 

4.  Pressure  upon  varicose  veins. 

5.  Surgical  operations. 

6.  Coition. 

7.  High  altitudes. 

8.  Hot  vaginal  injections  and  baths. 

What  are  internal  causes  ? 

1.  Infectious  diseases  (acute). 
Abortion  due  to  (a)  High  temperature. 

{b)  Hemorrhagic  endometritis, 
(c)  The  infection  of  the  foetus. 

2.  Chronic  diseases,  especially  syphilis. 


PREGNANCY.  87 

3.  Causes  due  to  the  uterus. 

(a)  Displacements. 

(b)  Endometritis. 

(c)  Structural  disorders. 

4.  Pelvic  adhesions. 

5.  Tumors. 

6.  Lead  poisoning. 

7.  Working  in  tobacco. 

8.  Organic  diseases  of  the  kidneys. 

9.  Sneezing,  coughing,  vomiting,  diarrhoea,  and  dysentery. 

10.  Mental  emotions. 

11.  Emmenagogue  medicines. 

What  are  the  ovular  causes  ? 

Any  of  the  diseases  which  may  cause  the  death  of  the  embryo 
or  foetus,  such  as 

1.  Diseases  of  the  decidua. 

2.  Diseases  of  the  placenta. 

(a)  Apoplexy. 
(6)  Inflammation. 

(c)  Fatty  degeneration. 

(d)  Syphilis. 

(e)  Myxomatous  degeneration. 

3.  Polyhydramnios. 

4.  Placenta  praevia. 

5.  Infectious  diseases. 

6.  Diseases  and  compression  of  the  cord. 

Are  some  women  liable  to  a  recurrence  of  abortion  ? 

Yes.  Habit  is  not  to  be  regarded  as  a  factor ;  it  is  always  due 
to  the  original  predisposing  cause  still  acting. 

How  are  the  symptoms  of  abortion  classified  ? 
Into  premonitory  and  characteristic  symptoms. 

What  are  the  premonitory  symptoms  ? 

These  are  rarely  absent  after  the  second  month.  They  are  pel- 
vic weight  and  fulness,  pains  in  the  lumbar  and  sacral  regions, 
irritability  of  the  bladder  or  rectum,  alternate  sensations  of  chilli- 


88  ESSENTIALS    OF    OBSTETRICS. 

ness  and  heat,  and  a  feeling  of  malaise;  the  secretions  of  the  vagina 
are  also  increased. 

What  are  the  characteristic  symptoms  ? 

Hemorrhage  and  painful  uterine  contractions. 

Abortions  occurring  in  the  first  two  months  resemble  a  profuse 
menstrual  flow,  associated  with  dysmenorrhoea.  The  pain  is  caused 
by  uterine  congestion  and  by  the  expulsion  of  clots.  These  symp- 
toms continue  for  four  or  five  days,  and  the  product  of  conception 
is  expelled  from  the  vagina,  surrounded  by  clots,  or  in  fragments, 
along  with  the  decidua. 

In  abortions  occurring  prior  to  three  months,  the  ovum,  as  a 
rule,  is  expelled  entire;  subsequent  to  three  months,  the  ovum 
generally  ruptures  and  the  foetus  is  expelled,  while  the  appendages 
are  retained  for  a  greater  or  less  length  of  time. 

Hemorrhage  is  less  likely  to  occur  the  nearer  the  abortion  takes 
place  to  the  seventh  month.  The  uterine  decidua  is  more  easily 
thrown  off  in  late  than  in  early  abortions.  After  the  placenta 
is  formed  the  source  of  the  hemorrhage  is  from  the  placental  site; 
but  before,  it  is  from  the  entire  surface  of  the  uterine  cavity. 

What  are  the  immediate  dangers  of  abortion  ? 

1.  Hemorrhage. 

2.  Septicaemia. 

3.  Tetanus  (rare). 

What  are  the  remote  dangers  ? 

1.  Chronic  parenchymatous  metritis  (subinvolution.) 

2.  Placental  polypus. 

3.  Misplacements  of  the  uterus. 

Under  what  conditions  is  an  abortion  inevitable  ? 

1.  Death  of  the  embryo  or  foetus. 

2.  An  extensive  detachment  of  the  ovum. 

3.  Eupture  of  the  ovum. 

How  is  a  beginning  abortion  recognized  ? 

By  the  painful  uterine  contractions,  hemorrhage,  dilatation  of 
the  cervix,  and  the  ovum  felt  through  the  os  uteri. 


PREGNANCY.  89 

How  is  the  treatment  of  abortion  divided  ? 

1.  The  propliylactic  treatment. 

2.  The  treatment  of  threatened  abortion. 

3.  The  treatment  of  inevitable  abortion. 

What  is  the  prophylactic  treatment  ? 

This  consists  in  treating  the  cause  of  an  abortion.  Either  syphilis, 
or  retroflexion  of  the  uterus,  or  endometritis,  is  most  frequently 
found  to  be  the  cause  in  frequently  recurring  abortions. 

The  patient  should  avoid  all  active  exercise,  especially  during 
that  period  of  gestation  in  which  she  has  been  in  the  habit  of 
aborting.  She  should  also  rest  at  the  time  of  the  menstrual  epochs. 
Sexual  intercourse  is  often  the  cause  of  an  abortion  and  should  be  * 
forbidden.  Sir  J.  Y.  Simpson  recommended  the  chlorate  of  potas- 
sium in  certain  diseases  of  the  placenta ;  it  may  be  given  in  doses 
of  ten  to  twenty  grains  three  times  daily.  In  cases  of  habitual 
abortion  the  fluid  extract  of  viburnum  prunifolium  has  been  ad- 
vised ;  it  may  be  given  three  times  daily  in  doses  of  half  a  tea- 
spoonful  to  a  teaspoonful.  The  danger  of  abortion  occurring  is 
greatly  lessened  after  the  fourth  month. 

What  is  the  treatment  of  threatened  abortion  ? 

In  all  cases  occurring  in  the  early  months  of  pregnancy  there 
should  be  an  examination  made  to  ascertain  the  position  of  the 
uterus.  If  it  is  found  retroflexed  or  retroverted,  it  should  at  once 
be  replaced.  The  general  treatment  of  threatened  abortion  is  as 
follows :  The  patient  should  be  placed  in  bed  with  light  covering, 
and  given  cold  drinks ;  laudanum  should  be  administered  per  rec- 
tum (twenty  drops)  every  hour  for  three  or  four  hours  if  the  uterine 
contractions  continue.  Suppositories  of  opium  may  be  used  in 
palce  of  laudanum.  If  there  be  restlessness  and  excitement,  give 
twenty  to  thirty  grains  of  chloral  along  with  one  of  the  injections 
of  laudanum.  The  urine  should  be  drawn  with  a  catheter  twice 
in  the  twenty-four  hours ;  the  bowels  should  be  emptied  every 
other  day  by  means  of  an  injection,  or  by  a  mild  laxative.  The 
patient  should  remain  in  bed  for  a  week  after  all  symptoms  have 
disappeared.  If  there  be  a  recurrence  of  the  symptoms,  she  should 
immediately  return  to  bed. 


90  ESSENTIALS    OF    OBSTETRICS. 

What  are  the  indications  and  the  treatment  of  inevitable 
abortion  ? 

To  control  the  hemorrhage  and  to  empty  the  uterus. 

To  meet  these  indications  the  tampon  should  be  used,  at  the 
same  time  administering  internally  the  fluid  extract  of  ergot.  If 
the  hemorrhage  is  grave,  tampon  the  entire  vagina,  and  apply  a 
T  bandage ;  if  slight,  tampon  only  the  upper  third  of  the  vagina. 
The  tampon  may  remain  twelve  or  twenty-four  hours,  when  it 
should  be  removed  ;  if  the  hemorrhage  continues,  it  should  be  re- 
peated. Generally  after  the  removal  of  the  tampon  the  ovum  will 
be  found  in  the  vagina,  or  it  may  have  descended  into  the  cervical 
,canal ;  in  the  latter  case  the  ovum  forms  a  plug,  and  it  may  now 
be  necessary  to  repeat  the  tampon ;  compression  of  the  uterus, 
under  these  circumstances,  will,  in  some  cases,  expel  the  ovum. 
Great  care  should  be  taken  in  the  first  three  months  not  to  rupture 
the  ovum,  as  there  would  be  great  danger,  if  the  accident  occurred, 
of  the  abortion  being  incomplete.  Before  using  the  tampon  empty 
the  bladder,  and  wash  out  the  vagina  with  a  solution  of  corrosive 
sublimate,  1  part  to  2000  ;  the  balls  of  absorbent  cotton  first  intro- 
duced into  the  vagina  should  be  dipped  in  carbolized  water  or 
covered  with  iodoform.  After  the  removal  of  the  tampon,  again 
wash  out  the  vagina  with  the  solution  of  corrosive  sublimate. 

In  abortion  occurring  in  the  first  two  months,  no  active  treat- 
ment, as  a  rule,  is  necessary  ;  the  patient  should  be  kept  at  rest  in 
bed  for  several  days. 

In  cases  of  complete  abortion  active  treatment  is  rarely  necessary; 
the  ovum  forms  a  plug  which  occupies  the  cervical  canal  and  con- 
trols the  hemorrhage. 

What  are  the  uses   of  the  tampon  in  the  treatment  of 
abortion  ? 

1.  To  control  hemorrhage. 

2.  To  stimulate  contractions  of  the  uterus. 

3.  To  assist  in  the  separation  of  the  ovum  from  the  uterus  by 
allowing  blood  to  accumulate  between  them. 

What  is  the  treatment  of  an  incomplete  abortion  in  the  first 
three  months  ? 

1.  The  expectant  plan ;  or 

2.  The  active  plan. 


PREGNAISrCY.  91 

Those  who  follow  the  expectant  plan  of  treatment  advise  waiting 
until  the  appendages  have  been  separated  from  the  uterine  cavity ; 
this  is  indicated  by  hemorrhage  followed  in  a  day  or  two  by  an 
offensive  discharge.  The  os.is  then  dilated  with  Hegar's  hard- 
rubber  dilators,  and  the  uterine  cavity  washed  out  with  a  warm 
solution  of  corrosive  sublimate,  1  pai^  to  3000.  Next  one  or  two 
fingers  are  introduced  into  the  uterine  ci.  ntj,  at  the  same  time 
making  firm  pressure  externally  with  the  other-  hand  upon  the 
fundus  of  the  uterus;  or  the  uterus  may  be  drawn  down  with  the 
volsella,  and  then  the  fingers  introduced.  After  detachiUj,  the 
membranes  they  are  carried  down  to  the  os  uteri  where  they  can 
be  seized  by  the  finger  and  thumb  and  withdrawn. 

If  the  digital  method  fails,  Emmet's  curette  forceps  should  be 
used.  After  the  appendages  have  been  entirely  removed,  Churchill's 
tincture  of  iodine  should  be  applied  to  the  uterine  cavity. 

Those  who  employ  the  active  plan  of  treatment  immediately 
empty  the  uterus  of  the  retained  appendages  by  means  of  either 
forceps  or  curettes. 

The  strictest  antiseptic  precautions  should  be  employed  in  the 
treatment  of  incomplete  abortion.  The  hands  and  instruments 
should  be  rendered  thoroughly  aseptic ;  the  vagina  and  uterine 
cavity  should  be  washed  out  with  a  solution  of  corrosive  sublimate 
before  and  after  the  removal  of  the  remains  of  the  ovum. 

What  is  the  indication  for  treatment  in  an  incomplete 
abortion  subsequent  to  the  fourth  month  ? 

To  empty  the  uterus. 

Expression  of  the  uterus  will  generally  cause  the  placenta  and 
membranes  to  be  expelled ;  other  cases  require  dilatation  of  the 
OS  and  the  use  of  the  fingers  or  the  curette  forceps. 

Should  the  uterine  cavity  be  washed  out  with  an  antiseptic 
solution  after  a  complete  abortion  ? 

No;  not  unless  symptoms  of  septicaemia  occur.  The  uterus 
should  only  be  irrigated  in  those  cases  requiring  the  introduction 
of  the  fingers  or  instruments  into  its  cavity. 


92  ESSENTIALS    OF    OBSTETKICS. 

What    antiseptic  precautions    should    be  taken  after  an 
abortion  ? 

The  vagina  should  be  washed  out  with  a  warm  solution  of  cor- 
rosive sublimate,  1  part  to  2000,  immediately  after  the  ovum  is 
expelled.  The  external  organs  should  be  bathed  twice  a  day  with 
a  solution  of  corrosive  sublimate,  and  kept  covered  with  corrosive 
sublimate  gauze. 

What  is  the  after-treatment  of  abortion  ? 

The  patient  must  remain  at  rest  in  the  recumbent  position  for 
the  same  length  of  time  as  after  a  labor  at  full  term. 

What  is  the  indication  for  treatment  in  missed  abortion  ? 

To  empty  tbe  uterus. 

Ectopic  Development  of  tbe  Ovum. 

How  is  ectopic  gestation  divided  ? 

Into  1.  Primitive  cervical  pregnancy. 
2.  Extra-uterine  pregnancy. 

What  is  primitive  cervical  pregnancy  ? 

The  arrest  and  development  of  the  ovum  in  the  cervical  canal; 
this  variety  of  ectopic  gestation  is  very  rare,  and  abortion  occurs 
in  the  first  three  months. 

What  are  the  varieties  of  extra-uterine  pregnancy  ? 

1.  Tubal. 

(a)  Interstitial. 
(6)  Tubo-abdominal. 
(c)  Tiibo-ovarian. 

{d)  Pregnancy  in  the  rudimentary  cornu  of  a  one-horned 
uterus. 

2.  Abdominal. 

[a)  Primary. 
(6)  Secondary. 

3.  Ovarian. 

Describe  the  cause,  course,  and  termination,  of  tubal  preg- 
nancy. 

Cause. — Inflammations  of  the  mucous  membrane  associated  with 


PREGNANCY.  93 

loss  of  the  ciliae;  dilatation  and  hernial  pouches;  flexions  and 
constrictions;  polypus;  pelvic  tumors  pressing  upon  the  tube,  and 
occlusion  due  to  inflammation.  In  cases  of  complete  occlusion 
there  is  a  transmigration  of  the  spermatozoids ;  cases  of  trans- 
migration of  the  ovule  occur  in  some  cases.  The  tube  may  be 
large  enough  for  the  spermatozoids  to  enter,  but  too  small  to  allow 
the  ovum  to  pass  through.  Cases  are  recorded  of  two  ovules  pass- 
ing through  the  tube  at  the  same  time,  the  one  in  advance 
blocking  the  way  of  the  other;  the  former  developing  in  the 
uterus,  the  latter  in  the  tube. 

Course. — The  mucous  membrane  of  the  tube  undergoes  hyper- 
trophy, and  the  villi  become  attached  to  it.  Generally  the  uterine 
and  abdominal  openings  are  closed ;  in  some  cases  the  uterine 
opening  remains  patulous.  The  villi  of  the  chorion  forming  the 
placenta  penetrate  to  the  muscular  coat.  At  the  beginning  of 
pregnancy  the  muscular  coat  of  the  tube  thickens,  but  later  on  it 
becomes  thin,  due  to  the  stretching  caused  by  the  ovum. 

Termination. — Eupture  usually  occurs  within  the  first  two  or 
three  months ;  in  some  cases  the  pregnancy  may  go  on  to  term. 
After  rupture  the  entire  ovum,  or  only  the  embryo  or  foetus  may 
escape  into  the  abdominal  cavity,  or  in  some  cases  the  entire  ovum 
may  remain  in  the  tube.  Eupture,  in  nearly  all  cases,  is  followed 
by  death  caused  either  by  internal  hemorrhage  or  peritonitis. 
Eecovery  may  occur  when  the  product  of  conception  dies  prior  to 
rupture.  Eupture  may  occur  between  the  folds  of  the  broad  liga- 
ment ;  this  is  spoken  of  as  extra-peritoneal  pregnancy. 

Describe  the  course  of  an  interstitial  pregnancy. 

This  variety  of  extra-uterine  pregnancy  is  also  known  as  tubo- 
uterine.  The  ovum  is  developed  in  that  portion  of  the  oviduct 
which  passes  through  the  wall  of  the  uterus.  In  the  beginning  of 
pregnancy  the  muscular  tissue  undergoes  hypertrophy,  and  forms 
a  sac  around  the  ovum.  As  a  rule,  the  ovum  develops  more 
rapidly  than  the  muscular  tissue,  and  rupture  takes  place  generally 
prior  to  the  fourth  month ;  in  rare  cases  gestation  may  go  on  to 
term.  When  the  ovum  is  situated  near  the  uterine  cavity  it  may 
be  expelled  into  the  uterus  and  abortion  follow. 


94  ESSENTIALS    OF    OBSTETRICS. 

Describe  the  course  of  tubo-abdominal  and  tubo-ovarian  preg- 
nancies. 

Tubo-abdominal. — The  ovum  is  developed  ia  the  ampulla  of  the 
oviduct  and  growing  outward  extends  into  the  abdominal  cavity. 
It  is  surrounded  by  the  broad  ligament,  the  ovary,  the  mesentery, 
the  bladder,  the  intestines,  and  the  uterus,  which  are  all  bound 
together  by  a  plastic  exudation,  the  result  of  a  local  peritonitis. 
In  the  beginning  of  gestation  the  ovum  descends  into  Douglas's 
cul-de-sac.  The  external  covering  of  the  ovum  in  advanced  preg- 
nancy may  include  the  liver,  kidneys,  and  spleen.  The  placenta 
is,  as  a  rule,  formed  in  the  pelvic  cavity. 

Tubo-ovarian. — The  external  sac  of  the  ovum  is  formed  by  the 
oviduct  and  ovary,  which  are  surrounded  and  bound  together  by  an 
inflammatory  exudation. 

In  both  of  the  above  varieties  of  extra-uterine  gestation  their 
course  and  termination  are  like  those  of  an  abdominal  gestation. 

Describe  the  course  of  pregnancy  in  the  rudimentary  cornu 
of  a  one-horned  uterus. 

This  variety  is  in  close  anatomical  relation  with  the  tubal  form. 
Rupture,  as  a  rule,  takes  place  between  the  third  and  sixth  months. 
Tbe  apex  of  the  horn  is  the  portion  in  which  rupture  takes  place. 
In  a  case  reported  by  Turner,  pregnancy  continued  on  to  term.  In 
a  case  cited  by  Koeberle,  the  foetus  died  during  the  fifth  month, 
and  was  formed  into  a  lithopaedion. 

The  formation  of  the  placenta  is  more  perfect  in  this  variety  of 
extra-uterine  gestation. 

Describe  the  course  of  abdominal  pregnancy. 

This  variety  is  divided  into  primary  and  secondary  abdominal 
pregnancy.  The  former  is  very  rare ;  the  latter  begins  at  first  as 
one  of  the  varieties  of  tubal  pregnancy.  The  sac  usually  contains 
muscular  fibres.  The  placenta  may  be  attached  to  any  of  the 
abdominal  or  pelvic  organs.  Cases  are  on  record  of  the  ovum 
being  free  in  the  abdominal  cavity,  i.  e.,  not  surrounded  by  pseudo- 
membranes.  The  pregnancy,  in  many  cases,  goes  to  term,  when 
the  foetus  dies  and  either  becomes  cartilaginous  or  is  converted 
into  a  lithopsedion  or  into  adipocere ;  the  ovum  being  retained  for 
many  months  or  even  years.    On  the  other  hand,  suppuration  may 


PKEGNANCY.  95 

occur,  and  the  cyst  rupture  into  the  bowel  or  bladder,  or  discharge 
its  contents  through  the  abdominal  wall. 

Describe  an  ovarian  pregnancy. 

In  this  variety  the  fecundation  and  growth  of  the  ovum  take 
place  within  the  ovisac.  In  some  cases  the  ovum  may  pass  through 
the  opening  caused  by  the  rupture  of  the  ovisac,  and  thus  lie 
almost  entirely  within  the  abdominal  cavity.  In  ovarian  preg- 
nancy rupture  usually  takes  place  in  three  or  four  months ;  rarely 
the  gestation  may  go  to  term. 

What  are  the  symptoms  of  extra-uterine  gestation? 

It  is  convenient  to  divide  the  symptoms  into  three  periods,  as 
follows:  1,  to  the  end  of  the  fourth  month,  i.  e.,  up  to  the  time 
when  the  sac  usually  ruptures ;  2,  from  the  fourth  month  to  the 
completion  of  spurious  labor ;  3,  from  the  completion  of  the  labor 
to  a  period  subsequent  to  the  death  of  the  foetus  (Parry). 

First  Period. — During  the  first  six  weeks  the  symptoms  of  intra- 
uterine pregnancy  may  be  present,  more  or  less  modified.  Men- 
struation usually  ceases,  the  uterus  enlarges  up  to  a  certain  point, 
and  a  decidua  is  formed  ;  a  plug  of  mucus  fills  the  cervix.  The 
changes  in  the  mammary  glands  occur ;  there  is  gastric  irritability, 
and  there  is  a  deposit  of  pigment  matter.  The  enlargement  of  the 
uterus  is  greatest  in  the  interstitial  variety.  From  the  second  to 
the  fourth  month  severe  intermittent  pains  occur  in  the  hypogas- 
trium.  They  are  associated  with  great  prostration  or  syncope; 
these  symptoms  may  last  for  several  hours  or  days.  The  pains 
are  probably  due  to  either  a  local  peritonitis,  to  contractions  of 
the  uterus,  or  to  stretching  of  adhesions.  During  this  period 
frequent  discharges  of  dark,  clotted  blood  occur  from  the  uterus; 
in  some  cases  portions  of  the  decidua  are  found  mixed  with  the 
discharge.  A  vaginal  examination,  after  the  first  six  weeks,  shows 
the  uterus  to  be  enlarged  and  displaced;  usually  forward,  in  some 
cases  upward,  or  laterally.  On  the  side,  or  behind  the  uterus,  is 
felt  a  cystic  tumor  more  or  less  tender  to  the  touch.  It  is  some- 
what immovable,  and  in  some  cases  ballottement  and  a  feeling  of 
obscure  fluctuation  can  be  detected. 

/Second  Period. — The  attacks  of  pain  lessen  in  frequency  or  dis- 
appear.    The  bloody   discharges   from   the   uterus   either   cease 


96  ESSENTIALS    OF    OBSTETRICS. 

altogether  or  are  greatly  lessened.  The  movements  of  the  foetus 
are  felt,  generally  on  one  side.  The  foetal  heart  sounds  are  dis- 
tinctly heard,  and  the  foetus  may  be  recognized  by  touch.  The 
abdomen  is  perceptibly  enlarged,  more  on  one  side  of  the  median 
line  than  on  the  other.  The  uterus  becomes  fixed  and  displaced 
higher  up.  An  examination  per  vaginam  reveals  a  fluctuating 
tumor  containing  a  solid  which  gives  the  sign  of  ballottement.  In 
some  cases  the  foetus  can  be  recognized.  The  tumor  causes  irrita- 
bility of  the  bladder  and  rectum. 

Third  Period. — This  period  is  characterized  at  full  term  by  a 
spurious  labor.  The  pains  closely  resemble  those  of  the  first 
stage  of  normal  labor.  After  continuing  for  several  hours  or  days 
they  cease.  Associated  with  the  spurious  labor  there  is  a  bloody 
discharge  from  the  vagina  containing,  in  some  cases,  portions  of 
the  decidua. 

Fourth  Period. — The  death  of  the  child  follows  the  false  labor. 
A  few  minutes  prior  to  its  death  very  active  movements  are  ob- 
served. After  the  death  of  the  child  the  liquor  amnii  is  absorbed, 
and  the  abdomen  lessens  in  size.  This  diminution  in  size  continues 
and  becomes  permanent  if  decomposition  does  not  take  place.  On 
the  other  hand,  if  decomposition  occurs,  symptoms  of  suppuration 
intervene. 

If  an  extra-uterine  pregnancy  continues  to  the  fourth  or  fifth 
month,  what  variety  is  it  likely  to  be  ? 
An  abdominal  or  ovarian ;  it  is  almost  certain  not  to  be  a  tubal. 

What  are  the  symptoms  of  rupture  of  the  cyst  ? 

The  patient  complains  of  griping  pains  in  the  lower  part  of  the 
hypogastrium,  which  are  followed  by  a  sudden  pain  of  great  severity; 
there  is  often  a  feeling  as  if  something  had  ruptured  inside  the 
abdomen.  These  symptoms  are  followed  by  great  prostration  and 
collapse.  Death  rapidly  ensues  or  the  patient  slowly  recovers 
from  the  collapse,  and  peritonitis  sooner  or  later  follows. 

What  is  the  treatment  of  extra-uterine  gestation? 

1.  Methods  to  destroy  the  life  of  the  embryo  or  foetus. 
Puncture. — This    consists   in   evacuating  the   liquor   amnii  by 
puncturing  the  cyst  with  a  trocar,  introduced  either  through  the 


PREGNANCY.  97 

rectum  or  vagina.  The  operation  is  not  recommended  on  account 
of  the  great  danger  to  the  mother ;  cases  are  recorded  where  the 
pregnancy  continued  after  the  operation. 

Injections  into  the  Cyst. — This  plan  is  both  uncertain  and  danger- 
ous.    Morphia  and  atropia  are  the  drugs  usually  employed. 

Electricity. — This  consists  in  the  use  of  the  faradic  or  galvanic 
current.  It  is  the  most  successful  method,  and  the  one  generally 
adopted  by  the  profession.  One  electrode  is  introduced  into  either 
the  rectum  or  vagina,  the  other  upon  the  abdominal  wall.  The 
treatment  should  be  employed  daily  for  from  five  to  ten  minutes, 
and  continued  until  lessening  in  the  size  of  the  cyst  indicates  that 
the  death  of  the  foetus  has  been  accomplished. 

2.  The  radical  treatment. 

The  indications  for  abdominal  section  are  summarized  by  J. 
Creig  Smith,  as  follows  : 

{a)  "In  all  cases  before  the  period  of  expected  tubal  rupture 
(2|  to  3f  months) ;  in  fact,  as  soon  as  the  condition  has  been  dis- 
covered, should  electricity  fail  to  kill  the  ovum." 

(6)  "  In  all  cases  of  tubal  rupture,  as  soon  as  possible  after  the 
condition  has  been  diagnosed." 

(c)  "  In  all  cases  up  to  the  fifth  month  in  which  the  foetus  con- 
tinues to  live.  Between  the  fifth  month  and  the  period  of  false 
labor,  operation  is  not  advisable." 

(d)  "  In  all  cases  after  false  labor  when  the  child  is  dead  and  the 
amnion  absorbed.  If  suppuration  takes  place,  operation  is  im- 
perative ;  if  the  foetus  is  quiescent,  operation,  though  advisable  in 
the  view  of  preventing  further  trouble,  is  not  urgent.  Absorption 
of  the  amnion  is  waited  for,  because  this  indicates  cessation  of 
circulation  in  the  placenta." 

(e)  '*  In  all  cases  where  the  condition  endangers  the  life  of  the 
mother.'' 

Placenta  Prsevia. 

What  is  placenta  prsevia  ? 

The  insertion  of  the  placenta  "  to  that  part  of  the  womb  which 
always  dilates  as  labor  advances"  (Rigby). 

What  are  the  varieties  of  placenta  praevia  ? 

1.  Central,  where  the  centre  of  the  placenta  is  directly  over  the 
internal  os  uteri. 

7 


98  ESSENTIALS    OF    OBSTETRICS. 

2.  Partial,  where  there  is  more  placental  tissue  on  one  side  'of 
the  OS  internum  than  on  the  other. 

3.  Marginal,  where  the  edge  of  the  placenta  reaches  down  to,  but 
not  over,  the  internal  os  uteri. 

4.  Lateral,  where  the  edge  of  the  placenta  is  near  the  os  uteri. 

How  often  does  it  occur? 

Once  in  about  1200  cases. 

What  is  the  hemorrhag'e  resulting  from  placenta  prsevia 
called  ? 

Unavoidable  hemorrhage. 

What  are  the  causes  of  placenta  prsevia  ? 

Authorities  do  not  agree  as  to  the  cause.  The  following  are 
some  of  the  theories : 

The  ovule  does  not  become  fecundated  until  it  reaches  the  lower 
part  of  the  cavity  of  the  uterus ;  the  impregnated  ovum  is  not 
arrested  in  the  upper  part  of  the  uterus  on  account  of  the  mucous 
membrane  not  being  sufficiently  swollen;  a  deviation  in  the  shape 
or  size  of  the  uterine  cavity ;  uterine  contractions  may  force  the 
impregnated  ovum  down  to  the  lower  portion  of  the  uterus ;  or  the 
oviducts  may  open  near  the  internal  os  uteri. 

It  is  more  frequent  in  the  multiparas  than  in  the  primiparge  (six 
to  one) ;  it  occurs  more  often  in  the  poor  than  the  rich ;  rapidly 
succeeding  pregnancies  and  abortions  also  predispose  to  placenta 
praevia. 

Bescribe  the  characteristics  of  the  placenta. 

It  usually  covers  a  larger  surface  of  the  uterine  cavity  than  when 
normally  implanted ;  it  is  thinner,  and  the  cord  is  usually  attached 
to  the  margin ;  occasionally  it  is  velamentous.  Prolapse  of  the 
cord  frequently  occurs  during  labor. 

What  is  the  characteristic  symptom  of  placenta  prsevia  ? 

Hemorrhage. — It  rarely  occurs  before  the  last  three  months  of 
pregnancy ;  Depaul  limits  the  time  in  nearly  all  cases  to  the  last 
month  and  a  half.  The  hemorrhage  is  sudden,  without  any  evi- 
dent cause,  and  is  intermittent.  The  first  hemorrhage  is  usually 
slight,  but  the  amount  of  blood  lost  increases  in  each  successive 


PKEGN-ANCY.  99 

attack.  If  the  first  attack  of  hemorrliage  occurs  near  the  end  of 
pregnancy,  it  may  be  so  profuse  as  to  place  the  life  of  the  patient 
in  danger.  Premature  labor  may  occur  after  several  attacks  of 
hemorrhage. 

What  is  the  source  of  the  hemorrhage  ? 

It  results  from  a  greater  or  less  detachment  of  the  placenta. 
The  chief  source  of  the  hemorrhage  is  the  uterine  surface ;  a  small 
amount  of  blood  comes  from  the  placental  surface. 

What  are  the  causes  of  the  hemorrhage  ? 

This  is  an  unsettled  question ;  the  following  are  some  of  the 
theories : 

Rupture  of  the  veins,  due  to  the  dilatation  of  the  cervix  (Portal 
and  Giffard)  ;  or  in  the  latter  months  the  cervix  grows  away  from 
the  placenta  (Levret) ;  or  the  placenta  develops  more  rapidly  than 
the  cervix  (Stoltz  and  Barnes). 

What  is  the  prognosis  of  placenta  prsevia  ? 

Grave  in  all  cases  to  both  mother  and  child.  In  general  terms 
the  maternal  mortality  is  25  to  30  per  cent. ;  the  foetal  from  50  to 
75  per  cent.  The  earlier  in  pregnancy  the  hemorrhage  occurs  the 
greater  the  amount  of  blood  lost,  and  the  shorter  the  time  between 
the  attacks  the  graver  the  prognosis  becomes.  The  great  dangers 
after  delivery  are  post-partum  hemorrhage  and  septicaemia. 

What  is  the  diagnosis  of  placenta  prasvia  ? 

It  is  impossible  to  recognize  placenta  prgevia  during  the  first 
half  of  pregnancy.  If  abortion  occurs,  the  ovum  is  expelled  with- 
out rupture  of  the  membranes ;  there  is  absence  of  pain  prior  to 
the  hemorrhage  and  at  the  time  of  expulsion. 

During  the  second  half  of  pregnancy,  a  hemorrhage  coming  on 
suddenly,  and  without  any  evident  cause,  should  be  looked  upon  as 
indicative. 

On  examination  per  vaginam  the  vault  of  the  vagina  feels  soft 
and  doughy,  and  in  some  cases,  where  the  insertion  of  the  placenta 
is  not  central,  it  will  be  found  thicker  on  one  side  than  on  the 
other ;  ballottement  cannot  be  demonstrated ;  the  cervix  is  elon- 
gated and  softened,  and  occasionally  its  vessels  can  be  felt  pul- 


100  ESSENTIALS    OF    OBSTETRICS. 

sating.     The  diagnosis  is  not  positive  unless  the  placenta  can  be 
felt  through  the  os. 

What  is  the  treatment  of  placenta  prsevia  ? 

If  the  hemorrhage  occurs  prior  to  the  viability  of  the  foetus,  and 
it  does  not  endanger  the  mother's  life,  Parvin  and  Playfair  advise 
the  expectant  plan  of  treatment.  If,  however,  the  hemorrhage  is 
grave,  then  the  pregnancy  must  be  ended.  Lusk,  on  the  other 
hand,  holds  that  the  pregnancy  should  be  ended  if  the  hemorrhage 
occurs  prior  to  viability,  whether  it  be  slight  or  profuse.  After  the 
viability  of  the  foetus  nearly  all  authorities  now  agree  that  the 
induction  of  premature  labor  is  indicated. 

The  expectant  plan  of  treatment  employed  prior  to  the  viability 
of  the  foetus  consists  in  absolute  rest  in  bed,  cold  drinks,  and  the 
use  of  opium  if  the  patient  is  restless  or  suffers  pain. 

The  nurse  should  be  instructed  in  the  use  of  the  tampon,  in 
order  to  prevent  loss  of  blood,  if  a  sudden  and  grave  hemorrhage 
occurs. 

In  the  treatment  of  placenta  praevia  by  the  induction  of  prema- 
ture labor  the  chief  indication  to  be  met  during  dilatation  of  the 
cervix  is  the  management  of  hemorrhage. 

If  the  cervix  is  rigid  and  undilated,  the  tampon  should  be 
employed.  The  tampon  assists  in  the  dilatation  of  the  cervix  and 
increases  the  force  of  uterine  contractions  ;  it  also  serves  as  a  plug 
to  control  the  hemorrhage.  The  tampon  should  be  removed  at  the 
end  of  four  hours,  according  to  Lusk;  Parvin  holds  that  "it  is 
doubtful  if  any  harm  will  result  should  a  properly  applied  anti- 
septic tampon  be  left  for  twenty-four  hours."  If  the  cervix  is 
found  to  be  sufficiently  dilated  after  the  removal  of  the  tampon, 
the  operator  may  use  either  Barnes's  dilators  or  turn  by  Braxton 
Hicks's  bimanual  method. 

If  the  former  be  decided  upon,  the  complete  dilatation  of  the 
cervix  is  accomplished  by  the  introduction  of  Barnes's  rubber 
bags.  The  dilator  of  Barnes  acts  not  only  as  a  plug  in  the  os  uteri, 
but  it  rapidly  causes  complete  dilatation  of  the  cervix. 

After  the  cervix  has  been  dilated  the  membranes  should  be 
ruptured  and  the  case  left  to  nature,  if  the  attachment  of  the 
placenta  is  not  central,  if  the  contractions  of  the  uterus  are  strong, 


PREGNANCY.  101 

and  if  the  presentation  is  favorable.  If  the  uterine  contractions 
are  weak,  small  doses  of  ergot  should  be  given.  The  general  indi- 
cations for  the  use  of  the  forceps  hold  good.  If  the  child's  head 
is  movable  and  does  not  exert  sufficient  pressure  to  control  the 
hemorrhage,  version  should  be  performed. 

If  the  implantation  be  central,  the  placenta  should  be  separated 
with  the  finger  from  around  the  cervix.  Barnes's  dilators  should 
then  be  introduced,  and  the  dilatation  of  the  cervix  completed. 
While  the  dilators  are  being  used  perform  pelvic  version  by  the 
external  method.  If  this  cannot  be  accomplished,  wait  until  the 
cervix  is  dilated,  and  then  perform  podalic  version. 

The  after-treatment  consists  in  guarding  against  post-partum 
hemorrhage ;  ergot  should  be  given  for  a  week  or  longer. 

Strict  antiseptic  measures  must  be  adopted  before  and  after 
delivery. 

A  description  of  the  methods  employed  by  Barnes,  Cohen, 
Davis,  Murphy,  and  Wilson  can  be  found  in  the  text-books  on 
obstetrics. 

Accidental  Hemorrhage. 

What  is  accidental  hemorrhage  ? 

Hemorrhage  from  the  separation  of  a  normally  situated  placenta. 

How  is  it  divided  ? 

Into  open  and  concealed  hemorrhage. 

Concealed  hemorrhage  occurs,  according  to  Goodell,  "  (a)  when 
the  placenta  is  centrally  detached,  and  the  blood  accumulates  in 
the  cul-de-sac  formed  by  the  firm  adhesion  of  its  margins  to  the 
uterine  walls.  (6)  When  the  placenta  is  so  detached  that  the 
blood  escapes  into  the  uterine  cavity  behind  the  membranes  near 
the  fundus,  (c)  When  the  membranes  are  ruptured  near  the  de- 
tached placenta  and  the  effused  blood  mingles  with  the  liquor 
amnii.  [d)  When  the  presenting  part  of  the  foetus  so  accurately 
plugs  up  the  maternal  outlet  that  no  existing  hemorrhage  escapes 
externally"  (Lusk). 

What  are  the  causes  of  accidental  hemorrhage  ? 

It  usually  occurs  in  multiparse,  especially  in  the  weak  and  sickly. 


102  ESSENTIALS    OF    OBSTETRICS. 

It  may  be  caused  by  inflammation  of  the  kidneys  (acute  or 
clironic),  by  anaemia,  or  by  placental  disease.  It  is  usually  caused 
by  violent  exercise  or  accidents ;  or  by  uterine  contractions,  or 
emotional  influences.  Certain  acute  diseases  have  also  been  given 
as  causes. 

What  are  the  symptoms  ? 

Extreme  collapse  and  severe  pain,  absence  or  great  feebleness 
of  the  pains  of  labor,  distinct  enlargement  of  the  uterus,  or  occa- 
sionally a  localized  distention  of  the  uterine  walls.  A  discharge 
of  pure  blood  or  blood  mixed  with  liqaor  amnii. 

In  the  concealed  variety  the  diagnosis  is  made  from  the  above 
symptoms. 

Accidental  hemorrhage  may  be  mistaken  for  rupture  of  the 
uterus.  Eupture  of  the  uterus,  however,  occurs  after  the  escape 
of  the  liquor  amnii,  and  is  followed  by  the  recession  of  the  pre- 
senting part  and  the  escape  of  more  or  less  of  the  foetus  into  the 
abdominal  cavity. 

What  is  the  prognosis? 

Unfavorable  for  both  mother  and  child.  The  prognosis  is  more 
favorable  in  the  open  variety. 

What  is  the  treatment  ? 

If  the  hemorrhage  is  slight  and  open,  the  expectant  treatment 
is  indicated. 

If  the  hemorrhage  is  grave,  immediate  delivery  must  be  accom- 
plished. Eupture  the  membranes  and  give  ergot.  If  the  os  be 
sufficiently  dilated,  deliver  by  forceps  or  podalic  version ;  Barnes's 
dilators  should  be  used  if  the  cervix  is  undilated.  Firm  com- 
pression should  be  made  upon  the  uterus. 

Eclampsia. 

Define  eclampsia. 

"An  acute  disease  coming  or  during  pregnancy,  labor,  or  the 
puerperal  state,  and  characterized  by  a  series  of  tonic  and  clonic 
convulsions,  affecting  at  first  the  voluntary  muscles,  and,  finally, 
extending  to  the  involuntary,  accompanied  by  a  complete  loss  of 


PKEGNAlSrCY.  103 

consciousness,  and  ending  by  a  period  of  coma  or  sleep,  which 
may  result  in  cur6  or  death  "  (Charpentier). 

What  is  the  frequency  of  eclampsia  ? 

Parvin  places  the  proportion  as  1  to  250  or  300  pregnancies; 
Lusk,  1  to  500. 

The  disease  is  more  frequent  in  pregnancy  or  in  labor,  than  in 
the  puerperal  state.  It  is  most  frequent  in  the  latter  months  of 
pregnancy. 

What  is  the  etiology  of  eclampsia  ? 

The  etiology  of  the  disease  is  still  an  unsettled  question.  The 
following  theories  have  been  advanced : 

1.  Cerebro-spinal  congestion. 

2.  General  or  cerebral  anaemia. 

3.  Anaemia  of  the  cerebro-spinal  centres,  with  congestion  of  the 
meninges. 

4.  Eclampsia  is  a  neurosis. 

5.  Eclampsia  depends  upon  a  poisoning  of  the  blood,  which 
renders  it  unfit  to  act  normally  upon  the  nervous  centres. 

(a)  Albumen. 
{b)  Urea. 

(c)  Carbonate  of  ammonia. 

(d)  Extractive  matters  (creatin,  creatinin,  leucin,  etc.). 

(e)  Soluble  toxic  ptomaines. 

How  are  the  symptoms  of  eclampsia  classified  ? 

Into  the  premonitory  symptoms  and  the  symptoms  of  the  attack; 
the  latter  is  subdivided  into  three  periods  as  follows : 

1,  Invasion ;  2,  tonic  convulsions ;  3,  clonic  convulsions. 

What  are  the  premonitory  symptoms  ? 

The  most  constant  symptoms  are  headache,  disturbance  of 
vision,  and  epigastric  pain.  Among  other  symptoms  may  be 
mentioned,  somnolence,  or  insomnia,  excitement,  vertigo,  vomiting, 
and  despondency. 

What  are  the  symptoms  of  the  attack  ? 

Period  of  Invasion. — Suddenly  the  eyes  become  fixed  and  then 
follows  a  short  period  of  quiet.     The  attack  then  commences  by 


104  ESSENTIALS    OF    OBSTETRICS. 

rapid  movements  of  the  eyelids,  and  of  the  alse  of  the  nose,  fol- 
lowed by  convulsive  twitchings  of  the  muscles  of  the  face.  The 
pupils  are  dilated  and  insensible  to  light,  the  mouth  deviates 
toward  the  left  side,  and  the  head  rotates  from  one  side  to  the 
other. 

Period  of  Tonic  Convulsions. — The  convulsive  movements  extend 
from  the  head  to  the  neck,  body,  and,  finally,  to  the  extremities. 
The  body  becomes  rigid,  the  back  is  strongly  arched,  and  the 
patient  rests  upon  the  bed  by  the  head  and  lower  extremities 
(opisthotonos).  The  arms  are  extended  and  rigid;  the  hands  are 
closed,  and  the  thumbs  are  flexed  upon  the  palms.  The  tonic 
spasms  involve  the  diaphragm  and  muscles  of  the  thorax,  respira- 
tion ceasing;  the  face  becomes  red  and  swollen;  the  tongue  is 
thrust  partially  out  of  the  mouth ;  the  saliva  becomes  frothy  and 
mixed  with  blood,  due  to  the  tongue  being  bitten  by  the  teeth. 
When  respiration  becomes  reestablished,  the  air  passes  out  with  a 
whistling  noise.  There  is  complete  loss  of  sensation  and  con- 
sciousness. The  stage  of  tonic  convulsions  lasts  from  ten  to  twenty 
seconds. 

Period  of  Clonic  Convulsions. — The  convulsions  begin  in  the 
muscles  of  the  face  and  extend  to  the  body  and  extremities.  The 
face  becomes  deeply  congested  and  horribly  contorted ;  the  jaws 
open  and  close  rapidly  ;  the  tongue  may  again  become  bitten ;  the 
respiration  is  irregular  and  noisy ;  the  saliva  becomes  frothy  and 
mixed  with  blood.  As  a  rule,  the  convulsions  do  not  cause  a 
change  in  the  position  of  the  patient.  In  some  cases,  however,  it 
is  necessary  to  use  force  to  keep  the  woman  in  bed.^  This  period 
lasts  from  one  to  two  minutes,  and  is  followed  by  coma  or  stupor. 
At  the  end  of  half  an  hour,  in  most  cases,  sensation  and  conscious- 
ness gradually  return. 

As  a  rule,  the  attack  is  followed  by  others ;  the  interval  in  some 
cases  may  be  only  a  few  minutes,  or  it  may  be  several  hours.  In 
rare  cases  there  is  only  one  attack,  which  is  followed  by  the  rapid 
recovery  of  the  patient. 

What  is  the  prognosis  ? 

The  prognosis  is  grave.  The  maternal  mortality  is  30  per  cent, ; 
the  foetal  50  per  cent.  Eclampsia  predisposes  to  post-partum 
hemorrhage  and  inflammations  during  the  puerperal  state. 


PREGNANCY.  105 

What  conditions  would  lead  to  a  favorable  prognosis? 

The  attacks  infrequent  and  mild,  recovery  of  consciousness  in 
the  intervals,  small  amount  of  albumen  in  the  urine,  steady  fall  of 
the  temperature,  and  the  later  in  pregnancy  or  labor  the  attacks 
occur. 

What  conditions  would  lead  to  an  unfavorable  prognosis? 

The  uterus  remaining  long  unemptied,  the  attacks  frequent  and 
severe,  and  occurring  early  in  pregnancy  or  labor,  the  coma  pro- 
found, the  urine  scanty  and  containing  a  large  amount  of  albumen, 
and  the  temperature  high. 

How  is  the  treatment  divided? 

Into  1.  Prophylactic;  2.  Curative;  3.  Obstetric. 

Describe  the  treatment  of  eclampsia. 

Prophylactic.  —  This  treatment  consists  in  a  milk  diet,  saline 
cathartics,  and  hot  baths.  If  the  quantity  of  albumen  be  large, 
the  diet  should  be  entirely  of  milk.  The  saline  cathartic  should 
be  given  every  other  morning.  On  the  morning  the  cathartic  is 
not  given,  the  patient  should  take  a  hot  bath,  the  temperature  of 
which  should  be  from  98°  to  100°.  The  patient  should  remain  in 
the  water  fifteen  minutes,  and  upon  coming  out  should  be  dried  and 
wrapped  in  a  warm  blanket  and  given  hot  milk  or  hot  water  to 
drink. 

Lusk  advises  the  tincture  of  the  chloride  of  iron  in  full  doses, 
for  its  diuretic  and  tonic  effect.  If  the  symptoms  indicate  that  an 
attack  is  imminent,  thirty  grains  each  of  chloral  and  the  bromide 
of  potassium  should  be  given  per  rectum.  A  hydragogue  cathartic 
should  be  administered  to  unload  the  bowel.  The  pressure  upon 
the  ureters  and  upon  the  renal  vessels  may  be  relieved  by  assum- 
ing the  knee-chest  position  several  times  a  day.  The  patient 
should  avoid  lying  upon  her  back.  Parvin  advises  "  moderate 
bleeding"  in  cases  in  which  the  urgency  of  the  symptoms  will  not 
admit  of  waiting  for  the  action  of  prophylactic  measures. 

Playfair  advises  small  doses  of  the  tincture  of  digitalis  along 
with  the  tincture  of  the  chloride  of  iron. 

The  milk  diet  should  be  continued  so  long  as  the  urine  contains 
albumen.     The  urine  should  be  examined  every  four  or  five  days. 


106  ESSENTIALS    OF    OBSTETRICS. 

If  no  albumen  has  been  found  in  the  urine  for  eight  days,  Char- 
pentier  advises  the  following  tonic : 

R . — Extract,  quiniae,  extract,  gentianae,  aa  5ij  ;  Ferri  subcarbon- 
atis,  gr.  XV ;  Pulv.  rhei,  q.  s.— M.  Ft.  pil.  No.  100.  Sig. — Take 
five  or  six  pills  during  the  day. 

Curative. — The  patient  should  have  her  clothing  loose;  she 
should  be  watched  to  prevent  her  from  falling  out  of  bed— her 
movement,  however,  should  not  be  restricted;  and  a  folded 
napkin  should  be  placed  between  the  teeth  to  prevent  the  tongue 
from  being  bitten. 

The  bowels  should  be  freely  acted  upon  by  the  compound 
powder  of  jalap,  elaterium,  calomel,  or  one  or  two  drops  of  croton 
oil  placed  upon  the  back  part  of  the  tongue;  a  stimulating  injec- 
tion should  also  be  given  per  rectum. 

Chloroform  should  be  given  by  inhalation  and  at  the  same  time 
thirty  to  forty  grains  of  chloral  injected  into  the  rectum  ("in  the 
yelk  of  an  egg  and  six  ounces  of  milk").  ■  The  chloroform  should 
be  given  in  full  doses  during  the  convulsions,  and  continued  in 
smaller  quantities  for  several  hours  ;  at  the  approach  of  another 
paroxysm  the  amount  should  be  again  increased.  It  may  be 
necessary  to  repeat  the  chloral  in  an  hour  or  two  ;  in  most  cases, 
however,  it  need  not  be  given  again  for  several  hours. 

The  advantages  of  venesection  are  disputed.  Lusk  advises  from 
eight  to  sixteen  ounces  of  blood  to  be  withdrawn  as  "the  first  step 
in  the  treatment  of  convulsions."  Parvin  holds  that  "  bleeding 
ought  not  to  be  regarded  as  universally  applicable." 

Morphia,  hypodermatically,  is  advised  by  some.  Lusk  gives  from 
one-sixth  to  one-quarter  of  a  grain,  repeating  the  dose  in  an  hour, 
if  there  is  a  return  of  the  convulsions.  He  also  combines  the 
bromide  of  potassium  along  with  chloral  in  rectal  injections; 
giving  thirty  grains  of  each  at  a  dose.  He  advises  the  inhalations 
of  chloroform  to  be  withdrawn  so  soon  as  the  effects  of  the  chloral 
and  bromide  are  developed. 

Obstetric. — If  the  uterus  be  emptied,  the  convulsions  cease  in 
about  one-third  of  the  cases.  During  the  first  stage,  if  the  pains 
are  weak,  a  catheter  should  be  carefully  introduced  into  the  uterus. 
The  dilators  of  Barnes,  if  required,  should  be  used  to  dilate  the 
cervix.     After  the  complete  dilatation  of  the  os,  the  forceps  should 


LABOR.  107 

be  applied  and  the  child  delivered.  Artificial  means  to  hasten 
labor  should  only  be  employed  in  those  cases  in  which  there  is  a 
clear  indication. 

"When  eclampsia  occurs  during  pregnancy,  Parvin  and  Lusk 
advise  the  induction  of  premature  labor. 

If  convulsions  begin  or  continue  after  delivery,  chloral,  or 
morphia,  and  chloroform  should  be  used.  Lusk  does  not  believe 
in  the  use  of  chloroform  in  the  treatment  of  eclampsia  during  the 
puerperal  state. 

LABOR. 

What  is  labor? 

"  Labor  is  the  physiological  end  of  pregnancy,  and  may  be  de- 
fined as  the  process  by  which  the  foetus  and  its  appendages  are 
separated  from  the  mother;  it  is  travail,  bringing  forth"  (Parvin). 

How  is  labor  classified  ? 

Into :  1.  Premature,  where  labor  occurs  after  the  foetus  is  viable 
and  before  full  term. 

2.  Postponed,  where  labor  occurs  after  full  term ;  the  foetus 
being  alive. 

3.  Missed,  where  labor  occurs  after  full  term ;  the  foetus  being 
dead. 

4.  Natural,  where  labor  takes  place  without  the  assistance  of  art. 

5.  Artificial,  where  nature  is  aided,  or  replaced  by  art. 

What  are  the  conditions  necessary  for  a  natural  labor  ? 

1.  Foetus.  —  The  size  must  not  be  larger  than  normal,  and  the 
presentation  must  be  favorable. 

2.  Mother. — The  parturient  canal  and  the  voluntary  and  invol- 
untary forces  must  be  normal. 

What  are  the  determining  causes  of  labor? 

This  question  is  as  yet  unsettled ;  the  various  theories  may  be 
found  in  the  text-books. 

What  are  the  efficient  causes  of  labor  ? 

The  contractions  of  the  uterus,  assisted  during  the  second  stage 
of  labor  by  the  abdominal  muscles. 


108  ESSENTIALS    OF    OBSTETRICS. 

What  are  the  precursory  symptoms  of  labor  ? 

(a)  Sinking  of  the  Uterus. — This  is  the  descent  of  the  fcetal  head 
enclosed  by  the  lower  portion  of  the  uterus  into  the  cavity  of  the 
pelvis.  The  waist  of  the  patient  becomes  smaller,  respiration  less 
difficult,  and  the  pressure  upon  the  stomach  is  relieved.  On 
account  of  the  pelvic  organs  being  pressed  upon,  the  bladder  and 
rectum  become  irritable ;  there  is  difficulty  in  locomotion,  and  the 
oedema  of  the  lower  limbs  is  increased.  The  sinking  of  the 
uterus  is  more  frequent  in  the  primigravida  than  in  the  multi- 
gravida ;  in  the  latter,  the  uterus  is  more  inclined  to  become  ante- 
verted.  Descent  of  the  uterus  generally  occurs  from  one  to  two 
weeks  prior  to  labor ;  in  some  cases  only  one  or  two  days,  in 
others,  one  month.  This  phenomenon  indicates  that  the  presenta- 
tion and  size  of  the  pelvis  are  normal. 

(6)  Secretions  from  the  Cervical  Glands.  —  A  profuse  glairy  secre- 
tion takes  place  from  the  glands  of  the  cervix.  As  labor 
approaches,  it  becomes  mixed  with  blood,  and  is  known  as  the 
"show."  The  blood  indicates  that  a  partial  detachment  of  the 
decidua  near  the  cervix  has  taken  place.  A  profuse  discharge 
indicates  that  the  cervix  will  dilate  rapidly. 

(c)  Changes  in  the  Vagina  and  External  Organs. — The  external 
genitalia  are  swollen  and  covered  by  a  copious  secretion  ;  the 
labia  majora  are  separated;  and  the  vagina  becomes  moist  and 
relaxed. 

{d)  Painless  Uterine  Contractions. — These  become  more  frequent. 
They  cause  little  or  no  discomfort  in  the  primiparae,  while  in  the 
multiparas  they  may  become  painful  several  days  before  labor. 

What  are  the  conditions  which  indicate  that  labor  has 
begun  ? 
Effacement  and  dilatation  of  the  cervix,  with  regularly  recurring 
uterine  contractions. 

Into  how  many  stages  is  labor  divided  ? 

Three.  First  stage,  or  "  uterine  period,^^  ends  with  the  complete 
dilatation  of  the  cervix ;  second  stage,  or  ' ' utero-abdominal  period" 
begins  after  complete  dilatation  of  the  cervix,  and  ends  with  the 
expulsion  of  the  child;  third  stage,  or  " placental  period,' '  includes 
the  detachment  and  expulsion  of  the  placenta. 


LABOK.  109 

How  are  the  phenomena  of  labor  divided  ? 

Into  the  physiological,  plastic,  and  mechanical  phenomena. 

What  are  the  "  characteristics  of  uterine  force  "  1 

1.  Involuntary. 

2.  Intermittent. 

3.  Peristaltic.  The  peristaltic  wave  begins  at  the  fundus  of  the 
uterus  ;  the  movements  are  so  rapid  that  practically  the  contrac- 
tic^ns  of  the  uterus  are  simultaneous. 

4.  Form  changes.  During  the  intervals  of  uterine  contraction 
the  uterus  is  ovoidal  in  shape.  During  contraction  the  transverse 
diameter  is  shortened,  while  the  antero-posterior  and  longitudinal 
are  somewhat  elongated.  The  modifications  in  the  diameters 
cause  the  uterus  to  become  more  or  less  cylindrical  in  shape. 

5.  Changes  in  position.  The  broad  and  round  ligaments  con- 
tracting press  the  uterus  against  the  brim  of  the  pelvis ;  the  latter 
also  incline  the  organ  anteriorly. 

6.  "  The  power  of  the  contractions  is  in  proportion  to  their  fre- 
quency and  resistance.'' 

7.  The  regularity  and  force  of  the  contractions  depend  upon  the 
presentation  of  the  foetus — e.  g.,  in  presentation  of  the  vertex  they 
are  more  regular  than  in  the  other  presentations. 

8.  The  contractions  are  painful.  The  character  of  the  pain 
varies  with  the  stages  of  labor.  The  pains  are  very  severe  in  some 
women,  while  others  suffer  but  little.  The  contractions  of  the 
uterus  begin  before  pain  is  recognized  by  the  patient,  and  continue 
after  all  suffering  has  ceased. 

What  are  the  character,  situation,  and  cause  of  the  pains 
during  the  first  and  second  stages  of  labor  ? 

First  Stage. — The  patient  speaks  of  the  pains  as  "  acute,"  or 
"grinding/'  or  *"' cutting."  The  pains  begin  in  the  lumbo-sacral 
region  and  extend  to  the  pubes,  from  whence  they  radiate  down 
the  thighs.  The  pains  are  caused  by  the  dilatation  of  the  cervix 
and  the  compression  of  the  uterine  nerves,  produced  by  the  con- 
tractions of  the  uterus. 

Second  Stage. — The  pains  give  a  sensation  of  stretching  or 
tearing.     The  patient  speaks  of  them  as  "  bearing- down  pains." 


110  ESSENTIALS    OF    OBSTETRICS. 

The  abdominal  muscles  are  now  brought  into  play,  adding  by  their 
contractions  to  the  pain  felt  by  the  patient.  There  is  an  intense 
sense  of  tearing  apart  of  the  vulvo-vaginal  canal  and  perineum ; 
cramps  occur  in  the  legs  ;  and  there  is  a  sensation  of  tenesmus  in 
the  rectum.  The  pressure  exerted  by  the  foetus  upon  the  nerves 
and  organs  of  the  pelvis  and  the  stretching  of  the  pelvic  soft 
parts,  are  the  obvious  causes  of  the  pains. 

Describe  the  process  by  which  the  cervix  is  dilated. 

At  the  beginning  of  labor  the  cervix  is  effaced,  and  the  border 
of  the  OS  uteri  is  felt  as  a  slight  projection  ;  it  is  more  distinct  in 
multiparse  than  in  primiparse.  As  the  os  dilates,  the  uterine 
cavity  decreases  in  size,  and  the  action  of  the  muscular  fibres  of 
the  body  of  the  uterus  draws  the  cervix  up  over  the  advancing 
part  of  the  foetus.  At  the  beginning  of  a  uterine  contraction,  the 
cervix  becomes  ''  thicker,  irregular,  as  if  puckered,"  and  the  os 
decreases  in  size;  later,  however,  the  cervix  becomes  thin,  and  the 
OS  increases  in  size.  As  dilatation  of  the  cervix  advances,  the 
decrease  in  the  size  of  the  os  does  not  take  place  at  the  beginning 
of  a  contraction. 

In  primiparse  the  cervix  is  very  thin  in  the  beginning  of  dila- 
tation. The  margins  of  the  cervix  feel  like  a  thick  thread.  As 
dilatation  advances,  the  cervix  becomes  thick  and  oedematous, 
especially  the  anterior  portion.  Dilatation  of  the  cervix  is  more 
rapid  in  multiparse  than  in  primiparse.  As  the  second  stage 
advances,  the  dilatation  is  more  rapid  than  in  the  beginning. 
As  labor  advances,  the  cervix  no  longer  points  posteriorly  and 
toward  the  left,  but  it  assumes  a  more  central  position.  The  shape 
of  the  OS  is  round  at  first ;  later  it  becomes  oval. 

The  following  is  the  mechanism  of  the  dilatation  of  the  cervix: 

1.  The  longitudinal  muscular  fibres  of  the  body  and  fundus  of 
the  uterus  overcome  the  action  of  the  circular  fibres  of  the  cervix, 
and  tend  to  pull  it  open. 

2.  The  pressure  of  the  membranes  and  the  presenting  part 
mechanically  dilates  the  cervix. 

3.  The  uterine  contractions  are  stimulated  by  the  pressure  of 
the  ovum  upon  the  cervix. 


LABOR.  Ill 

"What  is  the  bag^  of  waters  ? 

The  fcetal  membranes,  enclosing  the  liquor  amnii,  projecting 
through  the  os  uteri:  The  size  and  form  of  the  bag  of  waters  de- 
pend upon  the  presentation  of  the  foetus  and  upon  the  extent  of 
the  dilatation  of  the  os.  The  bag  of  waters  is  small  in  a  vertex 
presentation ;  it  has  at  first  the  shape  of  the  crystal  of  a  watch, 
but  later  it  becomes  hemispherical.  In  all  the  other  presentations 
it  is  large,  on  account  of  the  amount  of  liquor  amnii  in  advance  of 
the  foetus.  The  bag  of  waters  usually  ruptures  at  the  time  of 
complete  dilatation  of  the  cervix.  When  rupture  occurs  at  the 
end  of  pregnancy  or  in  the  beginning  of  the  first  stage,  the  labor 
is  spoken  of  as  a  "dry  labor."  In  catarrhal  endometritis  there 
is  a  collection  of  fluid  which  may  be  discharged  before  labor; 
this  discharge  is  spoken  of  as  the  *'  false  waters." 

What  is  the  diagnosis  of  the  rupture  of  the  bag  of  waters? 

Intact. — During  contractions:  The  bag  of  water  is  tense  and 
smooth.  The  liquor  amnii  is  felt  in  advance  of  presenting  part. 
Intervals  between  contractions:  The  bag  of  waters  is  flaccid,  and 
can  be  pressed  into  wrinkles. 

Ruptured. — During  contractions:  The  scalp  becomes  wrinkled. 
No  fore- waters.  Intervals  between  contractions:  The  scalp  gives 
a  different  sensation  to  the  examining  finger,  and  it  cannot  be 
pressed  into  wrinkles.  By  inserting  the  finger  between  the  head 
and  the  uterus  the  liquor  amnii  will  escape  into  the  palm  of  the 
hand. 

Describe  the  action  of  the  abdominal  muscles. 

These  muscles  assist  the  uterus  in  the  expulsion  of  the  foetus. 
They  are  not  brought  into  play  until  the  end  of  the  first  stage  of 
labor.  Their  action  is  voluntary,  and  remains  so  until  the  head  is 
being  expelled  from  the  vulva,  when  the  patient  loses  all  control, 
and  reflex  action  takes  the  place  of  voluntary  effort. 

Describe  the  dilatation  of  the  vagina  and  perineum. 

The  vagina  is  dilated  by  the  descent  of  the  presenting,  part,  and 
offers  but  little  resistance,  except  at  its  orifice.  At  this  point  the 
head  may  be  delayed  several  hours. 


112  ESSENTIALS    OF    OBSTETRICS. 

The  contractions  of  the  muscular  fibres  of  the  vagina  assist  in 
the  delivery  of  the  body  after  the  escape  of  the  head. 

The  perineum  becomes  slowly  distended  by  the  presenting  part 
until  it  measures  several  inches  in  length. 

At  each  contraction  the  head  advances,  but  it  recedes  again  in 
the  interval  of  utero-abdominal  effort.  The  stretching  of  the  peri- 
neum by  the  advancing  head  causes  the  anus  to  gape  wide  open  and 
expose  the  anterior  wall  of  the  rectum.  The  head  advances  and 
then  recedes  until  the  parietal  protuberances  escape  from  the  vulva, 
when  it  becomes  fixed.  A  strong  contraction  almost  immediately 
follows  and  the  head  is  born ;  the  perineum  passing  over,  first,  the 
anterior  fontanelle,  then  the  forehead,  and  lastly,  the  face  of  the 
child.  After  the  birth  of  the  head  a  short  interval  of  rest  fol- 
lows, when  contractions  again  come  on,  and  the  body  of  the  child 
is  expelled,  followed  by  a  discharge  of  liquor  amnii  mixed  with 
blood. 

How  long  after  the  birth,  of  the  child  is  the  placenta 
expelled  ? 

Usually  in  from  ten  to  twenty  minutes. 

How  is  hemorrhagic  prevented  after  the  detachment  pf  the 
placenta  ? 
By  the  blood  becoming  clotted  in  the  mouths  of  the  vessels,  but 
chiefly  by  uterine  retraction,  which  causes  the  muscular  fibres  of 
the  uterus  to  act  as  "living  ligatures." 

How  is  the  placenta  detached  and  expelled  from  the 
uterus  ? 

It  is  detached  by  uterine  retraction,  and  expelled  by  uterine 
contractions,  assisted  by  voluntary  efibrts. 

The  detachment  of  the  placenta  occurs  ''  almost  simultaneous  in 
all  parts." 

Playfair  agrees  with  Duncan  that  the  placenta  presents  by  its 
edge  at  the  mouth  of  the  uterus,  others  claim  that  the  fcetal  sur- 
face presents,  and  that  it  is  folded  upon  itself.  Parvin  is  of  the 
opinion  that,  in  all  probability,  the  part  which  presents  depends 


LABOR.  113 

upon  the  part  of  the  uterus  to  which  the  placenta  was  attached, 
•'and  upon  whether  the  membranes  are  separated  before  the 
uterine  contractions  which  expel  it  begin." 

What  are  the  effects  of  labor  on  the  mother  and  foetus  ? 

Mother. — During  a  uterine  contraction  the  arterial  pressure  is 
increased,  and  the  pulse  becomes  more  rapid ;  in  the  interval  of 
pain  the  pulse  declines  again  to  its  normal  condition.  During 
the  pains  the  respirations  become  slower ;  but  they  become  more 
rapid  in  the  intervals.  As  labor  advances  there  is  a  slight  pro- 
gressive rise  in  the  temperature.  The  urine  is  increased  in  amount. 
Vomiting  may  occur  during  the  first  stage ;  it  has  no  significance. 
If,  however,  it  occurs  during  the  second  stage,  and  is  associated 
with  weak  uterine  contractions  and  exhaustion,  immediate  delivery 
is  indicated. 

In  some  patients  a  "  slight  shivering  "  occurs  at  the  beginning  of 
a  uterine  contraction.  In  the  intervals  of  uterine  contractions 
patients  have  a  tendency  to  sleep,  this  results  from  fatigue,  and 
also  from  cerebral  congestion. 

Foetus. — There  is  a  slight  increase  in  the  rapidity  of  the  fcetal 
heart  at  the  beginning  of  a  uterine  contraction ;  it  becomes  slower 
during  the  height  of  a  contraction,  and  after  the  pain  passes  off 
it  becomes  more  rapid  than  normal  for  a  short  length  of  time. 
Discharges  of  urine  and  meconium  are  caused  by  pressure  upon 
the  foetus ;  a  discharge  of  meconium  is  frequent  in  breech  presen- 
tations. 

What  is  the  duration  of  labor  ? 

In  primiparse  the  average  is  seventeen  hours;  in  multiparse 
twelve  hours.  As  a  rule,  the  second  stage  is  one-third  that  of  the 
first  stage.  Labor  usually  begins  between  the  hours  of  9  and  12 
o'clock  at  night,  and  ends  between  9  o'clock  in  the  evening  and 
the  same  hour  in  the  morning. 

What  are  the  causes  of  false  labor-pains  ? 

Intestinal  irritation,  rheumatism  of  the  uterus,  and  contractions 
of  the  uterine  and  abdominal  muscles ;  the  first  is  the  most  frequent 
cause. 

8 


114 


ESSENTIALS    OF    OBSTETRICS. 


What  is  the  diagnosis  of  false  from  true  labor-pains? 

True  Pains. 
Premonitory  symptoms  of  labor. 
Begin   in   the  lumbo-sacral  re- 
gion and  extend  to  the  pubes. 
Regular  in  recurrence. 
Increase  in  severity. 
Dilatation  of  the  cervix. 
Eflfacement  of  the  neck. 


False  Pains. 
No  premonitory  symptoms. 
Felt  at  all  parts  of  the  abdo- 
men. 
Irregular. 

No  increase  in  severity. 
No  dilatation. 
No  effacement. 


What  do  you  mean  by  the  plastic  phenomena  of  labor  ? 

"The  foetal  form-changes  produced    in  labor,  and    dependent 
upon  presentation  and  position"  (Parvin).     The  alterations  in  the 

diameters  of  the   foetal  head  have 
already  been  discussed. 

What  is  the  caput  succeda- 
neum? 
A  swelling  upon  the  presenting 
part  of  the  foetus,  due  to  a  sero-san- 
guineous  infiltration,  the  result  of 
pressure.  The  infiltration  occurs 
upon  that  portion  of  the  present- 
ing part  not  subjected  to  pressure. 
The  size  of  the  tumor  depends  upon 
the  length  of  the  labor;  in  rapid 
deliveries  it  is  but  little  developed. 
The  caput  succedaneura  is  violet- 
colored  ;  it  pits  on  pressure,  but 
does  not  fluctuate. 


Formation  of  the  caput 
succedaneura. 


What  is  the  situation  of  the  caput  succedaneum  in  the 
various  presentations  ? 
Vertex. — L.  O.  A.,  on  the  posterior  and  superior  angle  of  the 
right  occipital  bone. 
R.  O.  A.,  on  the  posterior  and  superior  angle  of  the 

left  occipital  bone. 
L.  O.  P.,  on  the   superior  and  anterior  angle   of  the 
right  occipital  bone. 


LABOR. 


115 


R.  O.  P.,  on  the  superior  and  anterior  angle  of  the  left 
occipital  bone. 
Face. — Fronto-anterior  positions,  on  the  superior  portion  of  the 
malar  region,  and,  in  some  cases,  upon  the  eye. 
Fronto-posterior  positions,  on  the  superior  portion  of  the 
malar  region  and  upon  the  side  of  the  mouth. 
Breech. — As  a  rule,  upon  the  anterior  thigh ;  it  may  also  include 

the  external  genitals. 
Shoulder. — Upon  the  presenting  shoulder. 


Mechanism  of  Labor. 


What   do   you   mean   by  the   mechanical   phenomena   of 
labor? 

*'  The  passive  movements  given  the  foetus  in  its  expulsion." 
(Parvin.) 

How  many  presentations  of  the  foetus  are  given  ? 

Five:    1.  The  vertex. 

2.  The  face.  ^i^-  ^^ 

3.  The  breech. 

4.  The  right  shoulder. 

5.  The  left  shoulder. 

How    many    positions    are 
given    for    the    vertex, 
face,   and  breech? 
Four  each  :  1.  Left  anterior. 

2.  Right  anterior. 

3.  Right  posterior 

4.  Left  posterior. 


How  many  positions  are 
given  for  each  of  the 
shoulders  ? 

Two :    An  anterior  and  pos- 
terior position. 


Vertex  presentation. 


116  ESSENTIALS    OF    OBSTETRICS. 

"What  is  meant  by  presentation  ? 

"  That  part  of  the  fcBtus  which  is  in  relation  with  the  pelvic 
inlet"  (Parvin);  or  ''That  portion  of  the  foetus  which  occupies 
the  lower  segment  of  the  uterus"  (Lusk). 

What  is  meant  by  position  ? 

"  The  relation  which  the  presenting  parts  of  the  foetus  have  tq 
certain  fixed  points  of  the  inlet"  (Parvin),  These  fixed  points 
are  the  four  cardinal  points  of  Capuron ;  anteriorly,  the  ilio- 
pectineal  eminences ;  posteriorly,  the  sacro-iliac  joints.  The 
positions  of  the  shoulder  have  no  relation  to  these  points  on  the 
inlet. 

By  what  methods  can  the  diagnosis  of  presentation  and 
position  be  made  ? 

By  abdominal  palpation,  auscultation,  and  vaginal  touch  or  in- 
digation. 

How  is  the  diagnosis  of  presentations  made  by  ausculta- 
tion ? 

The  uterus  is  divided  into  four  parts  by  a  transverse  and  a  per- 
pendicular line.  The  former  divides  the  uterus  into  two  equal 
parts;  the  latter  corresponds  with  the  median  line  of  the  abdomen, 
and  extends  from  the  ensiform  cartilage  to  the  pubes.  As  the 
umbilicus  is  not  the  same  distance  above  the  pubes  in  all  cases, 
the  transverse  line  may  or  may  not  pass  through  it. 

The  maximum  of  intensity  of  the  foetal  heart  sounds  is  heard  as 
follows : 

Vertex  Presentations. — Below  the  transverse  line  and  to  the  right 
or  left  of  the  perpendicular  line. 

Face  Presentations. — On  the  transverse  line  and  to  the  right  or 
left  of  the  perpendicular  line. 

Breech  Presentations.-- — Above  the  transverse  line  and  to  the  right 
or  left  of  the  perpendicular  line. 

Shoulder  Presentations. — On  the  perpendicular  line,  midway  be- 
tween its  point  of  intersection  with  the  transverse  line  and  the 
pubes. 


LABOE.  117 

How  is  the  diagnosis  of  positions  made  by  auscultation  ? 

The  maximum  of  intensity  of  the  foetal  heart  sounds  is  heard  as 
follows  : 

Vertex. 

L.  0.  A.  Midway  on  a  line  extending  from  the  left  ilio-pectineal 
eminence  to  the  point  of  intersection  of  the  transverse  and  perpen- 
dicular lines. 

E..  O.  A.  At  the  same  point  on  the  right  side. 

E.  O.  P.  Midway  on  a  line  extending  from  the  right  sacro-iliac 
joint  to  the  point  of  intersection  of  the  transverse  and  perpendic- 
ular lines. 

L.  O.  P.  At  the  same  point  on  the  left  side. 

Face. 

L.  F.  A.  On  the  transverse  line  and  to  the  right  of  the  perpen- 
dicular line. 

E.  F.  A.  On  the  transverse  line  and  to  the  left  of  the  perpen- 
dicular line. 

E.  F.  P.  On  the  transverse  line  and  to  the  left  of  the  perpen- 
dicular line. 

L.  F.  P.  On  the  transverse  line  and  to  the  right  of  the  perpen- 
dicular line. 

Breech. 

Li.  S.  a.  At  a  point  near  the  perpendicular  line  on  a  line  ex- 
tending from  the  middle  of  last  left  false  rib  to  the  intersection  of 
the  transverse  and  perpendicular  lines. 

E.  S.  A.  At  the  same  point  on  the  right  side. 

E.  S.  P.  On  the  same  line  and  on  the  same  side  as  in  E.  S.  A., 
but  at  a  point  further  from  the  perpendicular  line. 

L.  S.  P.  On  the  same  line  and  on  the  same  side  as  in  L.  S.  A., 
but  at  a  point  further  from  the  perpendicular  line. 

Shoulder. 

The  shoulder  presenting  and  its  position  cannot  be  diagnosed 
by  auscultation.  Auscultation  gives  only  one  point  of  maximum 
intensity,  namely,  on  the  perpendicular  line  midway  between  its 
point  of  intersection  with  the  transverse  line  and  the  pubes. 


118  ESSENTIALS    OF    OBSTETRICS. 

What  is  meant  by  the  lie  of  the  foetus  ? 

The  relation  of  the  longitudinal  axi&  of  the  foetus  with  the  lon- 
gitudinal axis  of  the  uterus. 

If  the  longitudinal  axis  of  the  foetus  corresponds  with  the  longi- 
tudinal axis  of  the  uterus,  we  know  that  the  presentation  is  either 
a  vertex,  face,  or  breech.  On  the  other  hand,  if  the  axis  of  the 
foetus  is  oblique  in  its  relation  with  the  uterus,  we  know  that  a 
shoulder  is  presenting. 

How  is  the  foetal  head  recognized  by  palpation  ? 

By  its  being  hard,  round,  uniform  in  shape,  and  more  or  less 
movable. 

How  is  the  breech  recognized  by  palpation  ? 

It  is  felt  as  a  prominent  body,  broader  than  the  head  ;  it  is  less 
round  and  hard  and  lacks  the  same  uniform  shape  of  the  head ;  it 
is  also  immovable — i.  e.,  it  cannot  be  moved  without  displacing  the 
body  of  the  foetus.  Little  mobile  objects  are  felt  near  it,  which 
are  the  lower  extremities  of  the  foetus. 

How  is  the  back  recognized  by  palpation  ? 

It  is  felt  as  a  resisting,  expanded  mass,  which  connects  the  head 
with  the  breech. 

How  is  the  diagnosis  of  presentations  made  by  palpation? 

First  find  the  lie  of  the  foetus,  then  where  the  head  and  breech 
are,  and,  lastly,  differentiate,  if  the  head  presents,  between  the 
vertex  and  face. 

Vertex.  —  The  lie  of  the  foetus  is  longitudinal ;  the  head  is 
in  the  lower  segment  of  the  uterus,  and  the  breech  in  the  upper 
part. 

Now  with  the  head  in  the  lower  segment  of  the  uterus,  and  the 
breech  in  the  upper,  we  have  either  a  presentation  of  the  vertex 
or  face.  First  find  whether  the  back  is  anterior  or  posterior,  and 
then  toward  which  side  of  the  pelvis  it  points.  If  the  back  is  an- 
terior and  toward  the  left  we  know  that  the  position  must  be  left 
anterior.     If  it  be  a  vertex  presentation,  the  head  will  be  found 


LABOR.  119 

occupying  the  pelvic  cavity.  Again,  the  hand  will  sink  deeper 
into  the  left  side  of  the  pelvis  than  into  the  right ;  the  forehead 
being  on  the  right  side  offers  a  resistance.  Furthermore,  the 
occiput  will  be  found  to  be  continuous  with  the  back  and  not 
separated  from  it  by  a  deep  furrow  as  would  be  the  case  in  a  face 
presentation. 

Face. — The  lie  of  the  foetus  is  longitudinal ;  the  head  is  in  the 
lower  segment  of  the  uterus,  and  the  breech  in  the  upper  part.  If 
the  back  is  anterior  and  toward  the  left,  the  hand  will  sink  deeper 
into  the  right  side  of  the  pelvis,  on  account  of  the  left  side  being 
occupied  by  the  forehead.  Again,  the  head  will  be  found,  if  labor 
has  not  begun,  above  the  inlet,  not  low  down  and  occupying  the 
pelvic  cavity,  as  it  does  in  a  vertex  presentation.  In  some  cases 
the  inferior  maxillary  bone  may  be  felt ;  it  resembles  a  horseshoe- 
like swelling.  Furthermore,  a  deep  furrow  is  felt  between  the 
occiput  and  the  back  of  the  foetus.  In  a  face  presentation  the 
foetal  heart-sounds  are  heard  on  the  opposite  side  of  the  perpen- 
dicular line  and  not  on  the  side  toward  which  the  back  is  present- 
ing. This  is  not  so  in  a  vertex  or  breech  presentation,  and  this 
disagreement  between  palpation  and  auscultation  should  suggest 
to  the  practitioner  the  existence  of  a  face  presentation. 

Breech.  —  The  lie  of  the  foetus  is  longitudinal;  the  breech  is 
in  the  lower  segment  of  the  uterus  and  the  head  in  the  upper 
part. 

The  presenting  part  is  found  above  the  superior  strait  and  the 
pelvic  cavity  empty.  Again,  the  foetal  members  are  felt  near  the 
breech  in  the  lower  segment  of  the  uterus.  Furthermore,  the 
head,  which  is  in  the  upper  part  of  the  uterus,  is  found  to  be  freely 
movable. 

Shoulder. — The  lie  of  the  foetus  is  oblique  ;  the  head  occupies 
one  of  the  iliac  fossae  while  the  breech  is  on  the  opposite  side. 
The  head  is  lower  than  the  breech,  and  the  presenting  shoulder 
is  generally  in  the  plane  of  the  inlet.  The  pelvic  cavity  is  found 
to  be  empty,  as  is  also  the  case  in  a  face  or  breech  presentation. 
It  is  possible  to  perform  cephalic  ballottement.  Furthermore, 
the  shape  of  the  abdomen  is  changed,  being  increased  in  its 
transverse  diameter.  The  foetus  is  not  placed  in  a  transverse 
position — i.  e.,  the  head  does  not  occupy  one  iliac  fossa,  while  the 


120  ESSENTIALS    OF    OBSTETRICS. 

breech  occupies  the  other.  As  the  length  of  the  foetus  is  greater 
than  the  distance  between  the  iliac  fossae,  its  position  is  oblique, 
not  transverse. 

How  is  the  diagnosis  of  positions  made  by  palpation  ? 

Vertex. 

L.  O.  A.  The  back  is  found  anterior  and  toward  the  left,  and 
the  hand  sinks  deeper  into  the  left  side  of  the  pelvis  than  into  the 
right. 

R.  O.  A.  The  back  is  found  anterior  and  toward  the  right,  and 
the  hand  sinks  deeper  into  the  right  side  of  the  pelvis  than  into 
the  left. 

R.  O.  P.  The  anterior  plane  of  the  foetus  is  toward  the  front  of 
the  mother,  and  the  foetal  members  are  readily  felt.  The  resist- 
ance of  the  body  of  the  foetus  is  felt  on  the  right  side,  but  more  to 
the  right  and  further  back  than  in  a  R.  O.  A.  position.  The 
resisting  surface  felt  is  the  left  side  of  the  body  of  the  foetus.  Ro- 
tating the  woman  over  on  to  her  left  side,  the  abdomen  resting 
upon  the  bed,  we  can  map  out  the  back  of  the  foetus,  and  find  that 
it  is  directed  toward  the  right  sacro-iliac  joint.  Again,  the  hand 
sinks  deeper  into  the  right  side  of  the  pelvic  cavity  than  into  the 
left. 

L.  O.  P.  The  anterior  plane  of  the  foetus  is  tow^ard  the  front  of 
the  mother,  and  the  foetal  members  are  readily  felt.  The  resist- 
ance of  the  body  of  the  foetus  is  felt  on  the  left  side,  but  more 
to  the  left  and  further  back  than  in  a  L.  0.  A.  position.  The 
resisting  surface  felt  is  the  right  side  of  the  body  of  the  foetus. 
Rotating  the  woman  over  on  to  her  right  side,  the  abdomen  resting 
upon  the  bed,  we  can  map  out  the  back  of  the  foetus,  and  find  that 
it  is  directed  toward  the  left  sacro-iliac  joint.  Again,  the  hand 
sinks  deeper  into  the  left  side  of  the  pelvic  cavity  than  into  the 
right. 

Face. 

L.  F.  A,  'The  back  is  found  anterior  and  toward  the  left,  and 
the  hand  sinks  deeper  into  the  right  side  of  the  pelvic  cavity  than 
into  the  left. 

R.  F.  A.  The  back  is  found  anterior  and  toward  the  right,  and 


LABOR.  121 

the  hand  sinks  deeper  into  the  left  side  of  the  pelvis  than  into  the 
right. 

R.  F.  P.  and  L.  F.  P.  The  diagnosis  of  these  positions  is  made 
in  the  same  manner  as  in  R.  0.  P.  and  L.  O.  P.  positions. 

Breech. 

L.  S.  A.  The  breech  is  in  the  lower  segment  of  the  uterus,  with 
the  back  of  the-  foetus  anterior  and  toward  the  left  side  of  the 
mother's  pelvis. 

R.  S.  A.  The  breech  is  in  the  lower  segment,  with  the  back  of 
the  foetus  anterior  and  toward  the  right  side  of  the  mother's 
pelvis. 

R.  S.  P.  The  anterior  plane  of  the  foetus  is  toward  the  mother's 
front,  the  back  toward  the  right  sacro-iliac  joint. 

L.  S.  P.  The  anterior  plane  of  the  foetus  is  toward  the  mother's 
front,  the  back  toward  the  left  sacro-iliac  joint. 

In  making  a  diagnosis  of  the  posterior  positions  of  the  breech  by 
palpation  the  woman  should  be  rotated  upon  one  or  the  other  side, 
so  as  to  determine  the  direction  of  the  back. 

Shoulder. 

L.  D.  A.  The  head  will  be  found  in  the  right  iliac  fossa,  and 
the  breech  on  the  left  side  higher  up.    The  back  will  be  anterior. 

R.  D.  A.  The  head  will  be  found  in  the  left  iliac  fossa,  and  the 
breech  on  the  right  side  higher  up.     The  back  will  be  anterior. 

R.  D.  P.  The  head  will  be  found  in  the  right  iliac  fossa,  and  the 
breech  on  the  left  side  higher  up.  The  anterior  plane  of  the 
foetus  and  its  members  are  found  toward  the  front  of  the  mother. 

L.  D.  P.  The  head  will  be  found  in  the  left  iliac  fossa,  and  the 
breech  on  the  right  side  higher  up.  The  anterior  plane  of  the 
foetus  and  its  members  are  found  toward  the  front  of  the  mother. 

If  the  head  is  on  the  right  side  of  the  mother's  pelvis,  the 
position  is  either  a  L.  D.  A.  or  R.  D.  P.  •  If  the  back  is  anterior 
it  is  the  former,  if  posterior  the  latter.  Again,  if  the  head  is 
on  the  left  side  of  the  pelvis,  the  position  is  either  a  R.  D.  A.  or 
L.  D.  P.  If  the  back  is  anterior  it  is  the  former,  if  j)osterior  the 
latter. 


122  ESSENTIALS    OF    OBSTETEICS. 

How  is  the  diagnosis  of  presentations  made  by  vaginal 
touch  or  indication  ? 

The  diagnosis  by  indigation  is  practically  a  description  of  the 
surface  anatomy  of  the  part  presenting. 

Vertex. 

Before  Labor. — The  finger  feels  a  hard,  round  body  enclosed  in 
the  lower  portion  of  the  uterus.  If  the  lower  segruent  of  the  uterus 
is  thin,  the  sutures  and  fontanelles  may  be  recognized. 

During  Labor. — (a)  Before  rupture  of  the  bag  of  waters.  Vaginal 
touch  should  be  employed  in  the  interval  between  pains.  The 
head  is  felt  and  recognized  by  the  sutures  and  fontanelles.  If  the 
head  is  high  up  and  movable,  pressure  upon  the  hypogastrium  will 
cause  it  to  become  fixed  and  more  accessible.  If  indigation  be 
employed  during  a  contraction,  the  size  and  shape  of  the  bag  of 
waters  will  assist  in  the  diagnosis. 

(b)  After  rupture  of  the  bag  of  waters.  If  the  examination  be 
made  immediately  after  the  rupture,  the  sutures  and  fontanelles 
are  easily  recognized.  On  the  other  hand,  if  the  examination  be 
delayed,  the  formation  of  the  caput  succedaneum  will  render  the 
diagnosis  more  difficult.  Under  these  circumstances  if  the  finger 
be  carried  beyond  the  tumor  on  the  head,  the  sutures  and  fonta- 
nelles may  be  felt. 

Face. 

Before  Bupture  of  the  Bag  of  Waters. — The  diagnosis  is  difficult. 
Early  in  labor  the  forehead  may  be  mistaken  for  the  vertex.  We 
feel  the  anterior  fontanelle  and  may  mistake  the  fronto-parietal 
suture  for  the  sagittal.  If  it  be  a  vertex  presentation,  and  we  take 
the  anterior  fontanelle  as  the  starting-point,  and  follow  the  sagittal 
suture  posteriorly  we  find  that  it  ends  at  the  posterior  fontanelle. 
On  the  other  hand,  if  the  face  presents,  the  sagittal  suture  ends  at 
the  root  of  the  nose  and  superciliary  ridges. 

After  Bupture  of  the  Bag  of  Waters. — The  diagnosis  is  easy.  On 
one  side  of  the  pelvis  we  recognize  the  forehead,  a  hard,  round 
body,  also  the  fronto-parietal  suture,  terminating  at  the  anterior 
fontanelle.  Below  the  forehead  are  the  superciliary  ridges,  and 
the  projection  of  the  eyeballs.  Further  we  feel  the  nose  and  nos- 
trils, below  which  is  the  mouth. ,  The  tongue  can  be  felt,  and,  in 


LABOR.  123 

some  cases,  the  foetus  sucks  the  examining  finger.  Below  the 
mouth  is  felt  the  chin.  If  the  membranes  have  been  ruptured  for 
some  time,  a  face  presentation  may  be  mistaken  for  a  breech.  The 
cheeks  become  swelled,  and  a  furrow  forms  between  them;  the 
mouth  becomes  round,  and  the  caput  succedaneum  forms. 

The  nose,  however,  undergoes  no  change,  thus  preventing  an 
error  in  diagnosis. 

Breech. 

Before  Labor. — The  presenting  part  cannot  be  touched  by  the 
finger  on  account  of  its  high  position  in  the  pelvis.  In  some  cases 
by  forcing  down  the  fundus  of  the  uterus  the  breech  can  be  reached, 
but  even  then  it  is  generally  impossible  to  recognize  it.  The  breech 
is  softer  than  the  head  and  less  uniform  in  shape.  In  some  cases 
the  foetal  members  may  be  felt. 

During  Labor. — (a)  Before  rupture  of  the  membranes.  The  pre- 
senting part  being  high  up  and  the  bag  of  waters  very  large,  the 
sensations  imparted  to  the  examining  finger  are  far  from  clear. 
On  the  other  hand,  the  bag  of  waters  being  sausage-shaped  and 
the  presentation  high  up  would  be  in  favor  of  a  breech  presenta- 
tion, or,  at  least,  attract  attention. 

{b)  After  rupture  of  the  membranes.  The  breech  is  recognized 
by  being  less  round,  and  softer  than  the  head ;  by  the  absence  of 
fontanelles  and  sutures ;  by  the  groove  between  the  buttocks ;  the 
anus,  the  genital  organs,  and  the  coccyx,  the  latter  being  the 
salient  point  in  the  diagnosis;  the  anus  always  offers  a  resistance 
to  the  entrance  of  the  finger,  "  and  the  latter  upon  withdrawal  will 
be  covered  with  meconium."  If  the  feet  can  be  touched  by  the 
finger  the  diagnosis  is,  of  course,  easier. 

How  can  a  foot  be  distinguished  from  a  hand? 

Foot.  Hand. 

At  a  right  angle  to  the  leg.  In  the  prolonged  axis  of  the 

forearm. 

Os  calcaneum.     Malleoli. 

The  margins  of  unequal  thick-  The  margins  of  equal  thick- 
ness, ness. 

The  toes  are  placed  in  a  straight  The  thumb  is  not  on  the  same 

line.  plane  as  the  fingers. 


124  ESSENTIALS    OF    OBSTETRICS. 

Foot.  Hand. 

The  great  toe   cannot  be   sepa-  The  thumb  can  be  separated 

rated    from    the    second    and  from   the  index  finger  and 

brought   in   contact  with  the  brought  in  contact  with  the 

other  toes.  other  fingers. 

The  toes  are  short.  The  fingers  are  long. 

How  can  the  knee  be  distinguished  from  the  elbow  ? 

Knee.  Elbow. 

Broad.  Not  so  broad. 

The  patella  is  flat.  The  olecranon  is  pointed ;   the 

two  condyles  of  the  humerus 

can  be  felt. 
The  leg  and  thigh  are  thick.  The  arm  and  forearm  are  not 

so  thick. 

Shoulder. 

Before  Rupture  of  the  Bag  of  Waters. — The  presenting  part  is  out 
of  reach,  and  the  bag  of  waters  very  large,  rendering  the  diagnosis 
almost  impossible. 

After  Rupture. — The  following  are  the  landmarks :  The  ribs, 
called  by  Pajot  the  ''intercostal  gridiron; "  the  acromion ;  the  sca- 
pula and  its  spine ;  the  clavicle ;  and  the  axillary  cavity. 

How  is  the  diagnosis  of  positions  made  by  vaginal  touch  or 
indigatio'n  ? 

As  position  is  the  relation  v/hich  the  presentation  bears  to  one 
of  the  four  cardinal  points  of  Capuron,  it  naturally  follows  that  a 
point  of  reference  must  be  selected  upon  the  presenting  part  to  be 
in  relation  with  one  of  the  fixed  points  of  the  pelvis.  The  points 
of  reference  are  as  follows :  Vertex,  the  occiput ;  face,  the  fore- 
head ;  breech,  the  sacrum. 

Vertex. 

There  are  four  positions  of  the  vertex.  If  the  occiput  is  placed 
toward  the  left  ilio-pectineal  eminence,  L.  O.  A.;  if  to  the  right 
ilio-pectineal  eminence,  E.  O.  A.;  if  to  the  right  sacro-iliac  joint, 
R.  O.  P. ;  if  to  the  left  sacro-iliac  joint,  L.  O.  P. 

L.  O.  A.  The  sagittal  suture  is  in  the  right  oblique  diameter  of 


LABOE.  125 

the  pelvis ;  the  anterior  fontanelle  is  in  relation  with  the  right 
sacro-iliac  joint ;  the  posterior  fontanelle  is  directed  toward  the 
front  and  left  of  the  pelvis ;  and  the  occiput  is  at  or  near  the  left 
ilio-pectineal  eminence. 

R.  O.  A.  The  sagittal  suture  is  in  the  left  oblique  diameter ;  the 
anterior  fontanelle  is  in  relation  with  the  left  sacro-iliac  joint;  the 
posterior  fontanelle  is  directed  toward  the  front  and  right  of  the 
pelvis;  and  the  occiput  is  at  or  near  the  right  ilio-pectineal  emi- 
nence. 

R.  O.  P.  The  sagittal  suture  is  in  the  right  oblique  diameter; 
the  anterior  fontanelle  is  in  relation  with  the  left  ilio-pectineal 
eminence;  the  posterior  fontanelle  is  directed  toward  the  back 
and  right  of  the  pelvis ;  and  the  occiput  is  at  or  near  the  right 
sacro-iliac  joint. 

L.  O.  P.  The  sagittal  suture  is  in  the  left  oblique  diameter ;  the 
anterior  fontanelle  is  in  relation  with  the  right  ilio-pectineal  emi- 
nence; the  posterior  fontanelle  is  directed  toward  the  back  and 
left  of  the  pelvis;  and  the  occiput  is  at  or  near  the  left  sacro-iliac 
joint. 

Face. 

There  are  four  positions  of  the  face.  If  the  forehead  is  placed 
toward  the  left  ilio-pectineal  eminence,  L.  F.  A. ;  if  to  the  right, 
R.  F.  A. ;  if  to  the  right  sacro-iliac  joint,  R.  F.  P. ;  if  to  the  left, 
L.  F.  P. 

L.  F.  A.  The  nose  points  toward  the  right  sacro-iliac  joint,  and, 
therefore,  the  forehead  must  be  at  or  near  the  left  ilio-pectineal 
eminence.  The  chin  is  toward  the  right  sacro-iliac  joint.  The 
face  is  in  the  right  oblique  diameter. 

R.  F.  A.  The  nose  points  toward  the  left  sacro-iliac  joint,  and, 
therefore,  the  forehead  must  be  at  or  near  the  right  ilio-pectineal 
eminence.  The  chin  is  toward  the  left  sacro-iliac  joint.  The  face 
is  in  the  left  oblique  diameter. 

R.  F.  P.  The  nose  points  toward  the  left  ilio-pectineal  eminence, 
and,  therefore,  the  forehead  must  be  at  or  near  the  right  sacro-iliac 
joint.  The  chin  is  toward  the  left  ilio-pectineal  eminence.  The 
face  is  in  the  right  oblique  diameter. 

L.  F.  P.  The  nose  points  toward  the  right  ilio-pectineal  eminence, 
and,  therefore,  the  forehead  must  be  at  or  near  the  left  sacro-iliac 


126  ESSENTIALS    OF   OBSTETRICS. 

joint.     The  chin  is  toward  the  right  ilio-pectineal  eminence.     The 
face  is  in  the  left  oblique  diameter. 

Breech. 

There  are  four  positions  of  the  breech.  If  the  sacrum  is  toward 
the  left  ilio-pectineal  eminence,  L.  S  A. ;  if  to  the  right  ilio-pecti- 
neal eminence,  K.  S.  A. ;  if  to  the  right  sacro-iliac  joint,  E,.  S.  P. ; 
if  to  the  left  sacro-iliac  joint,  L.  S.  P. 

L.  S.  A.  The  coccyx  points  toward  the  right  sacro-iliac  joint: 
therefore,  the  sacrum  is  at  or  near  the  left  ilio-pectineal  eminence. 
The  groove  between  the  buttocks  is  in  the  right  oblique  diameter 
of  the  inlet. 

E.  S.  A.  The  coccyx  points  toward  the  left  sacro-iliac  joint: 
therefore,  the  sacrum  is  at  or  near  the  right  ilio-pectineal  eminence. 
The  groove  between  the  buttocks  is  in  the  left  oblique  diameter. 

E.  S.  P.  The  coccyx  points  toward  the  left  ilio-pectineal  emi- 
nence :  therefore,  the  sacrum  is  at  or  near  the  right  sacro-iliac  joint. 
The  groove  between  the  buttocks  is  in  the  right  oblique  diameter. 

L.  S.  P.  The  coccyx  points  toward  the  right  ilio-pectineal  emi- 
nence :  therefore,  the  sacrum  is  at  or  near  the  left  sacro-iliac  joint. 
The  groove  between  the  buttocks  is  in  the  left  oblique  diameter. 

Shoulder. 

There  are  two  positions  each  for  the  right  and  left  shoulder. 

Eight  Shoulder. — If  it  presents  with  the  back  anterior,  E.  D.  A. ; 
if  posterior,  E.  D.  P.  In  the  former  position  the  head  is  in  the 
left  iliac  fossa  and  the  breech  on  the  opposite  side ;  in  the  latter, 
the  head  is  in  the  right  iliac  fossa  and  the  breech  on  the  opposite 
side. 

Left  Shoulder. — If  it  presents  with  the  back  anterior,  L.  D.  A.  ; 
if  posterior,  L.  D.  P.  In  the  former  position  the  head  is  in  the 
right  iliac  fossa  and  the  breech  on  the  opposite  side ;  in  the  latter, 
the  head  is  in  the  left  iliac  fossa  and  the  breech  on  the  opposite 
side. 

E.  D.  A.  First  find  the  situation  of  the  head.  The  axillary 
space  represents  an  angle  with  its  apex  pointing  toward  the  head. 
Therefore  we  find  the  apex  of  the  axilla  pointing  toward  the  left 
side — the  position  of  the  head.     Now  if  the  head  is  in  the  left 


LABOR.  127 

iliac  fossa,  we  have  one  of  two  positions ;  either  a  R.  D.  A.  or  a 
L.  D.  P.  The  position  of  the  back  completes  the  diagnosis.  If 
we  feel  the  scapula  anterior,  we  know  that  the  back  of  the  foetus  is 
toward  the  front  of  the  mother;  in  some  cases  we  may  also  feel 
the  spinous  processes  of  the  vertebrae. 

E.  D.  P.  The  apex  of  the  axilla  points  toward  the  right  side — 
the  position  of  the  head.  Recognizing  the  clavicle,  we  know  that 
the  anterior  plane  of  the  foetus  is  toward  the  front  of  the  mother. 

L.  D.  A.  The  apex  of  the  axilla  points  toward  the  right  side — 
the  position  of  the  head.  Feeling  the  scapula  and  possibly  also 
the  spinous  processes  of  the  vertebrae,  we  know  that  the  back  is 
anterior. 

L.  D.  P.  The  apex  of  the  axilla  points  toward  the  left  side — 
the  position  of  the  head.  Recognizing  the  clavicle,  we  know  that 
the  anterior  plane  of  the  foetus  is  toward  the  front  of  the  mother. 

If  the  hand  is  outside  the  vulva,  how  can  we  determine 
whether  it  is  the  right  or  left  ? 

1.  Take  the  hand  of  the  child  and  shake  hands. 

2.  If  the  palm  of  the  hand  of  the  obstetrician  and  the  palm  of 
the  child's  hand  be  applied  flat  against  each  other,  and  the  thumbs 
of  the  two  hands  touch,  the  hand  of  the  child  will  be  left  if  the 
practitioner  is  using  his  right ;  right  if  using  his  left. 

3.  Turn  the  palm  of  the  child's  hand  up  toward  the  symphysis 
pubis  and  if  the  thumb  points  toward  the  left  side  of  the  mother, 
it  is  the  left  hand  f>resenting ;  if  to  the  right,  the  right  hand. 

Charpentier  gives  the  following  conclusions  : 

''The  hand  gives  us  the  shoulder;  the  dorsum  of  the  hand,  the 
situation  of  the  head ;  the  direction  of  the  thumb  indicates  the 
direction  of  the  back ;  for  when  the  back  is  posterior,  the  thumb 
points  upward  from  the  symphysis.  When  the  back  is  anterior, 
the  thumb  is  directed  downward  toward  the  anus.'' 

Into  how  many  stages  is  the  mechanism  of  labor  divided  ? 

Six. 

What  are  the  stages  of  the  mechanism  of  labor  in  a  vertex 
presentation  1 

1.  Stage  of  flexion. 

2.  Stage  of  descent  or  engagement. 


128  ESSENTIALS    IN    OBSTETKICS. 

3.  Stage  of  rotation. 

4.  Stage  of  extension. 

5.  Stage  of  external  rotation  of  the  head  and  internal  rotation 
of  the  body. 

6.  Stage  of  delivery  of  the  body. 

Describe  the  mechanism  of  labor  in  a  L.  0.  A.  position. 

First  Stage. — Flexion :  This  is  practically  rotation  of  the  head 
on  a  transverse  axis ;  the  chin  being  pressed  against  the  chest. 
Before  flexion  takes  place  the  occipito-frontal  diameter  is  in  rela- 
tion with  the  right  oblique  diameter  of  the  superior  strait  and  the 
biparietal  with  the  left.  After  flexion  has  occurred,  however,  the 
suboccipito-bregmatic  diameter  is  substituted  for  the  occipito- 
frontal. In  other  words,  a  short  diameter  takes  the  place  of  a 
long  one;  flexion,  therefore,  is  simply  a  movement  of  accommoda- 
tion. The  causes  of  flexion  are  as  follows :  First,  it  is  simply  an 
exaggeration  of  the  natural  position  of  the  foetus  (attitude).  Second, 
the  pressure  from  below  acts  with  more  power  upon  the  forehead 
than  it  does  upon  the  occiput,  on  account  of  the  distance  of  the 
former  from  the  occipital  foramen  being  greater  than  the  latter. 
In  other  words,  the  head  represents  a  lever,  having  arms  of  un- 
equal lengths;  pressure  from  below  causes  the  long  arm — the 
forehead — to  ascend,  while  the  short  arm — the  occiput— descends. 
Third.  ''If  a  propulsive  force  be  exercised  centrally  upon  a 
mobile,  and  there  be  resisting  forces  not  directly  opposite  to  each 
other,  but  at  different  levels,  rotation  of  the  mobile  occurs."  This 
law  of  mechanics  has  been  advanced  as  assisting  flexion. 

Second  Stage. — Descent:  The  descent  of  the  head  is  brought 
about  by  uterine  contractions,  assisted  by  the  action  of  the  abdom- 
inal muscles.  The  head  enters  the  pelvis  in  the  axis  of  the  inlet, 
and  continues  in  this  direction  until  the  curve  of  the  sacrum  and 
the  pelvic  floor  change  its  course. 

Levelling,  which  is  a  partial  extension  of  the  head,  occurring 
when  the  occiput  is  at  the  lower  border  of  the  ischio-pubic  fora- 
men, and  the  bregma  near  the  second  sacral  bone,  takes  place 
according  to  some  authorities.  It  is,  however,  of  no  importance 
in  the  mechanism  of  labor. 


LABOR.  129 

Third  Stage. — Rotation  :  This  movement  of  the  head  brings  the 
occiput  directly  in  front.  The  suboccipito-bregmatic  diameter  is 
now  in  relation  with  the  longest  diameter  of  the  outlet  (antero- 
posterior), and  the  bi-parietal  with  the  transverse.  While  the  head 
is  undergoing  this  change  of  position,  rotation  of  the  body  of  the 
fcetus  also  occurs. 

Authorities  do  not  agree  as  to  the  causes  of  the  phenomenon  of 
rotation.  The  following  are  the  explanations  given :  1.  The  law 
of  mechanics,  already  referred  to  as  explaining  rotation  on  a  trans- 
verse axis  (flexion).  2.  Pajot's  law  of  accommodation.  3.  Forces 
acting  on  a  lever  having  arms  of  unequal  lengths.  The  short  arm 
— the  occiput — moves  toward  the  front,  the  point  of  least  resist- 
ance. 4.  The  direction  given  the  occiput  by  the  inclined  planes 
of  the  pelvis. 

Fourth  Stage. — Extension :  Flexion  of  the  head  continues  until 
the  occiput  is  engaged  between  the  rami  of  the  pubes.  The  nape 
of  the  neck  now  becomes  fixed  against  the  subpubic  ligament ;  the 
chin  gradually  leaves  the  chest,  and  the  head  is  born  in  a  state  of 
extension.  During  this  stage  the  shoulders  lie  in  the  transverse 
diameter.  The  extension  of  the  head  is  the  resultant  of  two  forces 
— the  uterine  contractions  and  the  action  of  the  muscles  of  the 
pelvic  floor.  The  occif»ut  unable  to  advance  further,  the  uterine 
force  causes  the  chin  to  leave  the  chest  and  pushes  the  forehead 
beyond  the  apex  of  the  sacrum ;  the  perineum  then  drives  the 
occipito-frontal  diameter  forward.  When  the  bi-parietal  diameter 
has  passed  the  vulva,  the  perineum  retracts  and  gliding  over  the 
face  pushes  the  occiput  upward  against  the  symphysis  pubis. 

Fifth  Stage. — External  rotation  of  the  head  and  internal  rotation 
of  the  body :  After  the  expulsion  of  the  head  it  drops  down 
toward  the  anal  region,  and  a  contraction  of  the  uterus  coming 
on,  the  occiput  makes  a  quarter  rotation  toward  the  thigh  corre- 
sponding to  the  side  of  the  pelvis  in  which  it  was  originally  situ- 
ated. At  the  same  time,  rotation  of  the  body  occurs,  bringing  the 
shoulders  in  relation  with  the  longest  diameter  of  the  outlet 
(antero-posterior).  Restitution  is  a  rotation  of  the  head  occurring 
immediately  after  its  expulsion.  It  is  due  to  the  body  failing  to 
rotate  along  with  the  head  during  the  third  stage. 

Sixth  Stage. — Expulsion  of  the  body:  Uterine  action  continuing 

9 


130  ESSENTIALS    OF    OBSTETEICS. 

the  anterior  shoulder  passes  out  under  the  pubic  arch,  and  the 
upper  part  of  the  arm  becomes  fixed  at  the  subpubic  ligament. 
The  posterior  shoulder  sweeps  over  the  sacrum  and  pelvic  floor, 
causing  a  strong  lateral  flexion  of  the  body.  Finally,  the  shoulder 
is  born,  followed  by  the  arm,  and  then  the  anterior  arm  is  deliv- 
ered. The  delivery  of  the  trunk  rapidly  follows,  describing  a 
spiral  movement  as  it  passes  out.  The  same  mechanism  occurs 
as  in  the  birth  of  the  shoulders  if  the  hips  are  large. 

Describe  the  mechanism  of  labor  in  a  R.  0.  A.  position. 

The  mechanism  is  the  same  as  in  a  L.  O.  A.  position  already  de- 
scribed. 

Describe  the  mechanism  of  labor  in  a  R.  0.  P.  and  L.  0.  P. 
position. 

The  mechanism  is,  in  almost  all  cases,  the  same  as  in  the  anterior 
positions  of  the  vertex.  The  occiput,  as  is  the  rule  in  anterior  posi- 
tions, rotates  anteriorly,  the  nape  of  the  neck  coming  under  the 
symphysis  pubis.  Again,  restitution  is  more  frequent  in  posterior 
positions.  The  anterior  rotation  of  the  occiput  is  due  to  the  fact 
that  it  is  acted  upon  by  forces  which  cause  it  to  rotate  anteriorly 
in  the  direction  of  least  resistance  ;  this  is  the  application  of  the 
same  law  of  mechanics  referred  to  as  assisting  rotation  in  anterior 
positions. 

What  is  the  mechanism  of  labor  if  the  occiput  fails  to 
rotate  anteriorly  ? 

The  occiput  rotates  into  the  sacral  cavity,  and  descends  in  the 
axis  of  the  pelvis.  It  sweeps  over  the  pelvic  floor  and  escapes 
through  the  vulva,  the  neck  resting  upon  the  perineum.  The 
head  is  then  born  by  extension.  The  completion  of  labor  is  then 
effected  by  the  same  mechanism  that  occurs  in  an  anterior  rota- 
tion. Cases  are  on  record,  the  head  being  small,  of  the  presenta- 
tion being  changed  into  a  face  at  the  outlet.  The  chin,  under 
these  circumstances,  comes  under  the  symphysis  pubis  and  is  born 
first,  while  the  head  is  delivered  by  flexion.  These  cases  are  ex- 
tremely rare. 


LABOE.  131 

What  are  the  stages  of  the  mechanism  of  labor  in  a  face 
presentation  ? 

1.  Stage  of  extension. 

2.  Stage  of  descent. 

3.  Stage  of  rotation. 

4.  Stage  of  flexion. 

5.  Stage  of  external  rotation  of  the  head  and  internal  rotation 
of  the  body. 

6.  Stage  of  delivery  of  the  body. 

Describe  the  mechanism  of  labor  in  a  L.  F.  A.  position. 

First  Stage. — Extension:  The  object  of  complete  extension  is  to 
substitute  the  fronto-mental  diameter  for  the  mento-bregmatic ; 
in  other  words,  the  process  is  ©ne  of  accommodation.  Complete 
extension  is  due  to  the  fact  that  the  arms  of  the  face  lever  are  of 
unequal  lengths,  hence  the  face  being  driven  down  from  above 
meets  with  resistance,  causing  the  forehead  to  ascend,  while  the 
chin  descends.  Again,  the  original  position  of  partial  extension 
necessarily  favors  complete  deflection. 

Second  Stage. — Descent:  This  has  been  fully  explained  in  the 
description  of  the  corresponding  phenomenon  in  a  vertex  presen- 
tation. 

Third  Stage. — Rotation:  The  chin  rotates  anteriorly  and  comes 
under  the  symphysis  pubis,  while  the  forehead  is  in  relation  with 
the  sacrum.  The  forehead  rotates  posteriorly,  because  the  frontal 
arms  of  the  face  lever  being  longer  meet  with  greater  resistance 
anteriorly.  Again,  the  forehead  presenting  a  large  surface  finds 
more  room  in  the  sacral  cavity. 

Fourth  Stage. — Delivery  of  the  head  hy  flexion:  The  chin  escapes 
and  the  throat  pivots  under  the  symphysis  pubis.  The  chin  is  now 
pushed  up  over  the  pubic  joint,  while  the  face,  and,  finally,  the 
occiput,  is  born,  escaping  over  the  perineum.  After  the  birth  of 
the  occiput  the  head  sinks  toward  the  anal  opening. 

Fifth  Stage. — External  rotation  of  the  head  and  internal  rotation 
of  the  body :  The  mechanism  is  the  same  as  in  a  delivery  of  the 
vertex.  "  The  forehead,  or  the  chin,  always  turns  toward  that 
thigh  corresponding  with  the  side  of  the  pelvis  which  it  occupied." 


132  ESSENTIALS    OF    OBSTETRICS. 

Sixth  Stage. — Delivery  of  the  body :  The  mechanism  is  the  same 
as  in  vertex  delivery. 

What  are  the  anomalies  in  the  mechanism  of  labor  in  pre- 
sentations of  the  face  ? 

In  a  normal  mechanism,  the  chin  always  rotates  anteriorly,  in 
both  anterior  and  posterior  positions. 

The  following  are  the  anomalies  in  mechanism. 

1.  Extension  of  the  Head  may  be  only  Partial,  the  Forehead  Pre- 
senting.— Then,  one  of  two  conditions,  as  a  rule,  results.  Either 
flexion  occurs  and  the  vertex  presents,  or  extension  becomes  com- 
plete, and  the  face  offers ;  the  latter  is  the  more  frequent. 

2.  The  Face  may  be  Delivered  in  the  Transverse  Diameter. — This 
is  possible  in  a  rachitic  pelvis,  which  is  shallow,  flattened  in  the 
antero-posterior  at  the  inlet,  and  wide  between  the  ischia. 

3.  The  Chin  may  Rotate  into  the  Sacral  Cavity. — Spontaneous  de- 
livery is  impracticable  under  these  circumstances  at  full  term  with 
a  normal  pelvis.  For  the  head  to  be  delivered  the  chin  must  rest 
upon  the  anterior  margin  of  the  perineum.  But  the  distance  from 
the  tip  of  the  chin  to  the  sterno-clavicular  articulation  is  much 
less  than  the  length  of  the  sacral  wall;  hence,  as  the  pelvic  cavity 
is  already  occupied  by  the  head,  the  body  of  the  fcBtus  is  prevented 
from  descending ;  therefore,  delivery  cannot  take  place. 

What  are  the  stages  of  the  mechanism  of  labor  in  a  pelvic 
presentation  ? 

1.  Stage  of  compression,  or  moulding. 

2.  Stage  of  descent. 

3.  Stage  of  rotation. 

4.  Stage  of  delivery  of  the  body. 

5.  Stage  of  external  rotation  of  the  body  and  internal  rotation 
of  the  head. 

6.  Delivery  of  the  head. 

Describe  the  mechanism  of  labor  in  a  L.  S.  A.  position. 

The  first  two  stages  need  no  explanation  beyond  what  has 
already  been  given. 

Third  Stage. — Rotation:  The  anterior  hip  rotates  forward  under 
the  pubic  arch,  while  the  bistrochanteric  diameter  is  brought  in 


LABOR.  133 

relation  with  the  antero-posterior  diameter  of  the  pelvic  outlet. 
During  this  movement  of  the  hips  the  body  of  the  foetus  also 
rotates. 

Fourth  Stage. — Delivery  of  the  trunk :  The  anterior  hip  pivots 
against  the  subpubic  ligament,  while  the  posterior  hip  passes  over 
the  perineum  and  is  born.  The  anterior  shoulder  now  becomes 
fixed  at  the  pubic  arch,  while  the  posterior  shoulder  is  delivered 
first,  by  passing  over  the  perineum.  During  this  stage  of  the 
mechanism  the  upper  extremities  remain  closely  pressed  upon  the 
chest. 

Fifth  Stage. — External  and  internal  rotation :  The  occiput  now 
rotates  behind  the  symphysis  pubis,  while  the  face  turns  toward 
the  sacrum. 

Sixth  Stage. — Delivery  of  the  head:  The  nucha  pivots  upon  the 
subpubic  ligament,  while  the  head  is  born  strongly  flexed.  The 
chin  is  delivered  first,  followed,  finally,  by  the  occiput. 

What  are  the  anomalies  of  the  mechanism  of  labor  in 
pelvic  presentations  ? 

The  most  common  irregularity  in  the  mechanism  is  the  rotation 
of  the  occiput  into  the  sacral  cavity.  The  mechanism  now  de- 
pends upon  whether  the  head  remains  flexed  or  becomes  extended. 
In  the  former  case,  the  nape  of  the  neck  presses  against  the  ante- 
rior edge  of  the  perineum  and  the  head  is  born  by  flexion,  the 
occiput  passing  out  last,  the  back  of  the  child  being  directed 
toward  the  back  of  the  mother.  In  the  latter  case,  however,  the 
chin  remains  above  the  pubic  symphysis,  and  the  throat  rests 
against  the  subpubic  ligament.  The  head  being  born  extended, 
the  occiput  passes  out  first,  followed,  finally,  by  the  face.  The 
abdomen  of  the  child  is  directed  toward  the  abdomen  of  the 
mother. 

In  how  many  ways  may  spontaneous   delivery  occur  in 
shoulder  presentations  ? 
Three,  viz.  : 

1.  The  foetus  is  born  doubled;  this  can  only  occur  when  it  is 
very  small. 

2.  Spontaneous  version  ;  this  may  be  either  cephalic  or  pelvic. 

3.  Spontaneous  evolution. 


134  ESSENTIALS    OF    OBSTETRICS. 

What  are  the  stag-es  of  the  mechanism  of  labor  in  sponta- 
neous evolution? 

1.  Stage  of  compression. 

2.  Stage  of  descent. 

3.  Stage  of  rotation  of  the  shoulder. 

4.  Stage  of  delivery  of  the  trunk. 

5.  Stage  of  external  rotation  of  the  trunk,  and  internal  rotation 
of  the  head. 

6.  Stage  of  delivery  of  the  head. 

Describe  the  mechanism  of  labor. 

The  first  two  stages  need  no  further  description. 

Third  Stage. — Rotation:  The  presentatory  shoulder  rotates  ante- 
riorly, and  becomes  fixed  under  the  symphysis;  the  arm  protruding 
from  the  vagina. 

Fourth  Stage. — Delivery  of  the  body:  "  The  anterior  shoulder  re- 
maining fixed  under  the  symphysis  pubis  and  appearing  first, 
the  uterine  contractions  force  the  posterior  shoulder  (and  the  rest 
of  the  foetus)  from  above  downward,  making  it,  in  its  descent, 
sweep  along  the  posterior  Avail  of  the  excavation.  At  last,  urged 
on  by  the  contractions,  it  distends  the  perineum,  passes  the  poste- 
rior commissure,  and  is  followed  by  the  axilla,  the  thorax,  the  hips, 
the  breech ;  and  then  the  shoulder  fixed  under  the  symphysis  is 
disengaged  in  its  turn,  while  the  head  remains  in  the  uterus  to  the 
last." 

Fifth  and  Sixth  Stages. — These  are  the  same  as  in  breech  de- 
liveries. 

Should  a  presentation  of  the  shoulder  be  left  to  Nature? 

No.  The  delivery  of  the  foetus  must  always  be  accomplished 
by  art. 

Management  of  Labor. 

Anaesthesia. 

What  ag-ents  are  usually  employed  to  produce    general 
anaesthesia  in  labor  ? 

Ether,  chloroform,  chloral,  and  morphia. 

What  are  the  indications  for  anassthesia  in  labor  ? 

Ether  and  Chloroform. — Pain  is  the  special  indication  for  the 


LABOR.  135 

administration  of  an  anaesthetic  in  labor.  As  a  rule,  it  should  be 
used  in  the  second  stage  ;  however,  in  primiparse  it  is  often  given 
in  the  first  stage,  when  the  cervix  dilates  slowly  associated  with 
great  suffering.  The  anaesthetic  should  not  be  given  continuously; 
it  should  be  used  only  during  a  pain;  it  should  not  be  pushed 
to  the  extent  of  "  surgical,  but  obstetric  anaesthesia,"  but  during 
the  delivery  of  the  head  it  should  be  carried  to  complete  insensi- 
bility. 

Ether  should  be  used  in  preference  to  chloroform ;  the  latter  is 
unsafe,  as  it  acts  upon  the  motor  ganglia  of  the  heart  and  pro- 
duces sudden  heart  failure.  Again,  the  effect  of  chloroform  is  to 
relax  the  uterus,  causing  a  cessation  of  labor  pains,  and  rendering 
the  danger  of  post-partum  hemorrhage  greater.  Lusk,  and  others, 
hold  that  labor  does  not  give  an  "  absolute  immunity  "  from  the 
dangers  of  chloroform;  Parvin,  on  the  other  hand,  teaches  that 
the  freedom  from  danger  is  "  almost  complete." 

Chloral. — This  drug  is  especially  indicated  in  the  first  stage  of 
labor.  It  should  be  used  when  the  pains  cause  acute  suffering 
with  but  little  tendency  toward  dilatation  of  the  cervix.  No 
remedy  equals  it  in  its  action  in  a  case  of  rigid,  undilatable  cervix. 
Used  for  acute  suffering,  or  for  the  condition  just  stated,  it  should 
be  given  in  fifteen-grain  doses  every  twenty  minutes,  until  three 
doses  have  been  administered ;  in  some  cases  it  may  be  necessary 
to  give  an  additional  dose  in  an  hour  after  the  last  is  taken.  The 
drug  should  be  given  per  rectum  in  the  yelk  of  an  egg  and  six 
ounces  of  milk.  The  action  of  chloral  does  not  interfere  with  the 
subsequent  use  of  ether  or  chloroform,  but  rather  tends  to  increase 
their  efficiency.     Chloral  does  not  relax  the  uterus. 

Morphia. — This  drug  is  seldom  used  in  a  physiological  labor. 
When  indicated  it  should  be  given  hypodermatically. 

Preliminary  Preparations. 

What  articles  should  be  carried  by  the  obstetrician? 

A  stethoscope;  a  hypodermatic  syringe;  a  pair  of  obstetric 
forceps,  should  the  patient  live  at  a  distance;  an  elastic  catheter; 
needles,  needle-holder,  and  dressing-forceps;  sutures  (silk,  catgut, 


136  ESSENTIALS    OF    OBSTETKICS. 

silk-worm  gut,  or  silver  wire) ;    a  solution  of  morphia ;    the  fluid 
extract  of  ergot;  and  the  perchloride  of  iron. 

What  articles  should  be  provided  at  the  house  of  the 
patient  ? 
A  fountain  syringe ;  an  antiseptic  solution  ( R . — Hydrarg.  chlor. 
cor.  5j,  alcohol  f^j. — M.  Sig.  Teaspoonful  added  to  a  quart  of 
water  equals  1  part  to  2000);  sulphuric  ether;  a  half-dozen  pow- 
ders of  chloral,  each  containing  15  grains ;  absorbent  cotton ;  and 
a  ligature  for  the  cord.  Hot  and  cold  water,  brandy,  and  ice, 
should  be  kept  in  readiness.  One  word  in  reference  to  the  foun- 
tain syringe  and  hot  water :  these  are  of  absolute  importance,  and 
when  needed  must  be  had  on  the  instant.  No  physician  should 
attend  a  case  of  obstetrics  without  having  hot  water  and  a  syringe 
at  hand  to  control  post-partum  hemorrhage;  and  furthermore, 
antiseptic  measures  cannot  be  thoroughly  carried  out  without  the 
latter  article. 

How  should  the  bed  be  prepared  ? 

The  bed  should  be  placed  so  as  to  allow  access  from  both  sides, 
upon  it  place  a  hair  mattress,  or  one  made  of  some  firm  material; 
then  spread  a  rubber  cloth  over  the  lower  portion  of  the  mattress 
to  protect  it,  and  over  this  place  a  comforter  or  blanket.  Over  the 
comforter  spread  a  folded  sheet,  and  over  the  upper  part  of  the 
mattress  place  another  sheet  folded  once  upon  itself.  After  labor 
remove  the  rubber  cloth  and  everything  upon  it,  and  then  bring 
down  completely  over  the  mattress  the  lower  half  of  the  upper 
sheet. 

How  should  the  patient's  clothing  be  arranged  for  delivery  ? 

The  night  dress  or  chemise  should  be  raised  upon  the  hips,  and 
a  sheet  folded  once  secured  to  it  by  means  of  safety  pins.  After 
delivery  remove  the  sheet,  and  bring  the  chemise  down  over  the 
hips  and  limbs. 

First  Stage. 

What  is  the  management  of  the  first  stage  of  labor  ? 

Position  of  the  Patient. — The  patient  should  not  lie  down  in  bed, 
as  the  dilatation  of  the  cervix  and  the  descent  of  the  head  into  the 
pelvis  are  favored  by  the  upright  or  sitting  posture. 


LABOE.  137 

Bladder  ayid  Bedum. — She  should  pass  her  urine  frequently ;  if 
there  be  retention,  the  elastic  catheter  should  be  used.  If  the 
rectum,  at  the  time  of  making  a  vaginal  examination,  is  found  to 
contain  feces,  it  should  be  at  once  emptied  with  an  enema  of 
soap  and  water. 

Food  and  Drink. — Parvin  advises  the  use  of  simple  food  if  it  be 
required.  She  should  drink  cold  water ;  hot  teas  and  alcoholic 
drinks,  he  holds,  ought  to  be  forbidden.  Playfair,  on  the  other 
hand,  advises  beef-tea  to  be  freely  given,  and,  if  the  patient  be 
weak,  the  occasional  use  of  brandy  and  water. 

Vaginal  Examinations. — An  examination  should  be  made  every 
hour  to  ascertain  the  progress  of  the  labor. 

Membranes. — If  spontaneous  rupture  of  the  membranes  does  not 
occur  as  soon  as  the  cervix  is  fully  dilated,  they  should  be  arti- 
ficially broken.  This  may  be  readily  done  with  the  end  of  a  hair- 
pin pressed  against  the  amniotic  pouch  during  a  contraction  of  the 
uterus;  or,  the  nail  of  the  index  finger  may  be  nicked  in  one  or 
two  places  and  with  a  saw-like  motion  the  membranes  ruptured 
during  a  pain. 

Dilatation  of  the  Cervix. — The  dilatation  of  the  cervix  should  be 
left  to  nature.  Any  artificial  interference  with  this  process  is  un- 
justifiable in  normal  labor,  and  increases  the  dangers  of  septic 
infection. 

Attendance  of  the  Physician. — During  this  stage  the  obstetrician 
should  not  remain  constantly  with  the  patient. 

Second  Stage. 

What  is  the  management  of  the  second  stage  of  labor  ? 

Position  of  the  Patient. — The  patient  should  be  in  bed  during 
the  entire  time.  Before  the  head  has  reached  the  floor  of  the  pel- 
vis the  patient  should,  during  a  pain,  sit  up  in  bed,  with  her  feet 
fixed  and  her  hands  pulling  upon  a  sheet  attached  to  the  lower 
part  of  the  bed,  or  she  should  take  hold  of  the  hands  of  the  nurse. 
At  the  time  of  delivery  she  should  assume  the  left  lateral  position. 
This  position  lessens  the  danger  of  rapturing  the  perineum,  and 
enables  the  obstetrician  to  make  such  manipulations  as  may  be 
necessary. 


138  ESSENTIALS    OF    OBSTETRICS. 

Vaginal  Examinatiojis.  —  Immediately  after  the  rupture  of  the 
membranes  an  examination  should  be  made  per  vaginam  to  deter- 
mine the  increase  in  the  descent  of  the  head,  to  verify  the  diag- 
nosis of  presentation  and  position,  and  to  ascertain  whether  any 
complications  exist. 

During  this  stage  the  examinations  must  be  more  frequent,  so 
that  the  position  of  the  presenting  part  may  be  known  from  time 
to  time.  If  the  head  remains  stationary  for  two  hours  at  the  peri- 
neal floor,  labor  should  be  terminated  by  art. 

Condition  of  the  Cervix. — Artificial  dilatation,  as  a  rule,  should 
not  be  attempted.  If  the  cervix  be  directed  backward  and  to  the 
side,  hook  the  fingers  into  it  in  the  interval  of  a  pain,  and  draw  it 
toward  the  centre  of  the  parturient-canal.  Occasionally  the  ante- 
rior lip  of  the  cervix  becomes  impacted  between  the  head  and  the 
pubes,  in  which  case  it  becomes  swollen,  retarding  the  progress  of 
labor.  To  overcome  this  condition  press  up  the  anterior  lip,  in 
the  interval  of  a  pain,  with  two  fingers,  and  hold  it  above  the  head 
when  the  following  uterine  contraction  comes  on.  It  may  be 
necessary  to  repeat  this  manipulation. 

Management  of  the  Voluntary  Bearing-down  Efforts. — If  the  pains 
are  strong,  and  the  progress  of  labor  rapid,  voluntary  efforts  cer- 
tainly do  no  harm.  The  patient  should  bear  down  only  during 
a  pain.  When  the  head  distends  the  perineum  all  voluntary  effort 
should  stop,  and  the  patient  told  to  "  cry  out,"  otherwise  the  sud- 
den tension  upon  the  perineum  may  cause  a  laceration. 

When  the  labor  is  slow,  bearing-down  efforts  should  be  dis- 
couraged, as  they  only  unnecessarily  tire  the  patient.  During 
the  first  stage  of  labor  voluntary  efforts  are  not  only  useless  but 
injurious. 

Food,  Drink,  Rectum,  and  Bladder. — The  patient  will,  as  a  rule, 
require  but  little  food,  and  what  is  given  should  be  in  small  quan- 
tities and  simple.  Cold  water  will  be  all  that  is  needed  in  the  way 
of  drink.  The  patient's  face  and  hands  should,  from  time  to  time, 
be  bathed  with  cold  water. 

The  rectum  and  bladder  must  be  emptied.  The  patient  often 
expresses  a  wish  to  empty  the  bowels  during  this  stage.  This 
desire,  however,  is  caused  by  the  pressure  of  the  advancing  head 
upon  the  rectum. 


LABOR. 


139 


Preparation  for  Delivery. — The  following  articles  should  be  in 
readiness :  a  fountain  syringe,  hot  and  cold  water,  scissors,  a  liga- 
ture for  the  cord,  and  brandy  or  whiskey. 

Preservation  of  the  Perineum. 

The  position  of  the  patient  should  be  upon  the  side ;  the  knees 
drawn  up  toward  the  abdomen,  and  a  folded  pillow  placed  between 
them.  If  the  voluntary  bearing-down  efforts  cannot  be  controlled, 
give  an  anaesthetic.  If  the  perineum  is  not  sufficiently  relaxed  to 
allow  the  escape  of  the  head  without  producing  a  tear,  the  latter 
should  be  retarded  in  its  exit  by  direct  pressure.  To  accomplish 
this,  pass  the  left  hand  over  the  right  thigh  of  the  patient,  and 
with  the  thumb  on  the  occiput  and  the  fingers  on  the  anterior 
part  of  the  foetal  head,  hold  it  back  during  uterine  contractions. 

Fig.  3. 


Support  of  the  perineum. 

At  the  same  time  support  the  perineum  with  the  right  hand  so 
placed  that  the  fold  between  the  thumb  and  index  finger  is  in  rela- 
tion with  its  anterior  edge,  the  thumb  being  upon  the  right  while 
the  fingers  are  upon  the  left  side.  Make  moderate  pressure  during 
a  pain  in  the  direction  of  the  symphysis. 

Goodell  advises  introducing  one  or  two  fingers  into  the  rectum, 


140  ESSENTIALS    OF    OBSTETRICS. 

and  pulling  the  perineum  forward  .toward  the  symphysis ;  the 
thumb  at  the  same  time  making  pressure  on  the  head  so  as  to  re- 
tard its  progress,  Playfair's  method  is  as  follows:  "  If,  when  the 
head  is  distending  the  perineum  greatly,  the  thumb  and  forefinger 
of  the  right  hand  are  placed  along  its  sides,  it  can  be  pushed 
gently  forward  over  the  head  at  the  height  of  the  pain,  while  the 
tips  of  the  fingers  may  at  the  same  time  press  upon  the  advancing 
vertex  so  as  to  retard  its  progress  if  advisable."  I.usk  claims  by 
drawing  the  chin  downward  through  the  rectum  until  the  peri- 
neum is  distended  by  the  head,  and  then  allowing  recession  to 
take  place,  that  many  cases  of  rigidity  can  be  overcome,  and 
delivery  efiected  without  rupture,  the  head  being  born  in  the 
interval  of  pain. 

Episiotomy,  the  term  applied  to  the  operation  of  making  in- 
cisions into  the  perineum,  is  justifiable  when  a  rupture  seems 
inevitable.  The  incisions  should  be  lateral,  one  on  each  side  of 
the  central  raphe.  The  operation  should  be  done  during  a  pain,  at 
the  same  time  guarding  against  the  sudden  delivery  of  the  head. 
Lusk  claims  that  episiotomy  is  "  essentially  the  operation  of  young 
practitioners."  Be  that  as  it  may,  there  is  no  doubt  of  the  fact 
that  the  necessity  for  the  operation  is  rarely  if  ever  met  with. 

Birth  of  the  body.  When  the  head  is  expelled  it  should  be  held 
in  the  right  hand,  while  the  other  hand,  placed  upon  the  abdomen, 
follows  down  the  uterus  as  it  descends  and  forces  out  the  body. 
If  the  cord  is  coiled  around  the  neck  it  should  be  managed  as 
follows :  Enlarge  the  loop,  and  draw  the  cord  over  the  child's 
head,  or  deliver  the  shoulders  and  body  through  the  loop ;  if  these 
means-  fail,  divide  the  cord  and  ligate  each  end.  During  the 
delivery  of  the  shoulders  support  the  perineum.  Usually  after 
some  little  delay,  the  shoulders  are  delivered.  Their  expulsion 
should  be  left  to  uterine  contractions  which  may  be  strengthened 
by  friction  over  the  fundus  with  the  left  hand.  The  most  common 
cause  for  delay  in  delivery  is  an  arrest  of  the  anterior  shoulder 
beneath  the  symphysis.  To  liberate  the  shoulder  make  traction 
directly  downward  with  the  hands  placed  on  the  sides  of  the  head ; 
it  may  also  be  necessary  to  assist  the  expulsion  of  the  posterior 
shoulder  by  directing  the  head  up  toward  the  symphysis,  at  the 
same  time  making  slight  traction.     After  the  shoulders  are  de- 


LABOR.  141 

livered  the  body  is  rapidly  expelled;  if,  however,  there  be  any 
delay,  grasp  the  thorax  with  the  hands  and  make  gentle  traction. 

Care  of  the  Child. — Place  the  child  near  the  side  of  the  bed 
away  from  the  mother's  discharges  ;  care  being  taken  not  to  drag 
upon  the  cord.  If  respiration  does  not  occur,  clear  the  mucus 
from  the  throat  and  mouth  with  the  finger,  and  place  the  child  in 
a  basin  of  hot  water,  leaving  the  chest  exposed,  and  then  dash 
cold  water  upon  it  until  the  breathing  is  established.  Another 
good  plan  is  simply  to  rub  spirits  of  camphor  over  the  chest. 
After  the  cord  has  been  tied  the  child  should  be  handed  to  the 
nurse. 

Tying  the  Cord. — Tie  the  cord  "  when  the  child  breathes  freely 
and  the  pulsations  lessen  in  force."  In  tying  use  a  few  strands  of 
cotton  thread ;  use  two  ligatures,  one  "  about  three  fingers'  breadth 
from  the  umbilicus,"  the  other  "  at  a  distance  of  two  inches  from 
the  first  Mgature  and  toward  the  placenta."  Before  handing  the 
child  to  the  nurse  always  examine  the  cut  surface  of  the  cord  to 
see  if  the  ligature  controls  the  vessels.  Late  ligation  of  the  cord 
is  advised  by  some  authorities.  In  late  ligation  the  cord  is  not  tied 
until  the  pulsations  cease  entirely.  The  advantages  of  this  plan 
are  that  the  child  receives  more  blood  than  in  early  ligation,  and 
that  it  loses  less  weight  during  the  first  week  following  birth. 
Late  ligation  is  especially  indicated  in  children  who  are  born 
prematurely,  or  who  are  badly  nourished. 

Third,  or  Placental  Stage. 

What  is  the  management  of  the  third  stage  of  labor  ? 

Care  of  the  Mother. — The  patient  should  be  placed  upon  her 
back  after  the  delivery  of  the  child.  Immediately  after  the  birth 
the  nurse  should  place  her  hand  over  the  uterus  and  keep  it  there 
until  the  obstetrician  is  ready  to  attend  to  the  delivery  of  the 
placenta. 

Placental  Delivery. — The  indications  in  the  management  of  the 
third  stage  of  labor  are,  to  assist  in  the  delivery  of  the  placenta,  to 
keep  up  uterine  contractions,  and  to  prevent  hemorrhage. 

Crede's  method  is  the  plan  usually  employed  to  effect  expression 
of  the  placenta.     It  consists  in  making  at  first  gentle  and  then 


142  ESSENTIALS    OF    OBSTETKICS. 

stronger  frictions  over  the  fundus  and  body  of  the  uterus  through 
the  abdominal  wall.  During  a  uterine  contraction  the  hand  grasps 
the  uterus,  with  the  fundus  resting  in  the  palm,  while  the  sides 
are  compressed  between  the  fingers  and  thumb,  at  the  same  time 
making  moderate  pressure  in  a  downward  direction.  The  expul- 
sion of  the  placenta  from  the  uterus  is  generally  effected  after 
three  or  four  uterine  contractions.  After  the  placenta  has  been 
expelled  into  the  vagina,  traction  may  be  made  upon  the  cord, 
and  extraction  slowly  accomplished,  at  the  same  time  keeping  up 
pressure  upon  the  fundus  of  the  uterus.  As  the  placenta  is  with- 
drawn from  the  vagina,  Lusk  and  Playfair  advise  that  it  should 
be  revolved  so  as  to  twist  the  membranes  into  a  rope.  Parvin, 
however,  teaches  that  this  manoeuvre  is  not  necessary,  as  there  is 
no  danger  of  any  part  of  the  membranes  being  torn  off  if  the  pla- 
centa be  gradually  removed.  After  the  placenta  has  been  delivered 
the  obstetrician  should  examine  its  uterine  surface  to  be  sure  that 
no  portion  has  been  left  in  the  cavity  of  the  uterus. 

Administration  of  Ergot. — After  the  placenta  has  been  delivered 
give  the  patient  half  a  drachm  or  more  of  the  fluid  extract  of  ergot. 

Application  of  the  Binder. — The  binder  should  be  wide  enough 
to  extend  from  the  ensiform  cartilage  to  the  trochanters.  It  should 
be  pinned  securely  with  safety-pins;  the  pinning  either  begun 
above  or  below.  Unbleached  muslin  makes  a  very  good  bandage. 
In  case  it  is  necessary  to  use  compression  over  the  uterus,  the  fol- 
lowing plan  should  be  adopted:  "Make  three  firm  rolls  rather 
thicker  than  the  wrist,  of  as  many  towels ;  then  place  one  of  them, 
transversely  just  above  the  uterus  and  the  other  two  at  its  sides, 
and  let  the  bandage  be  pinned  firmly  over  them." 

How  should  the  cord  be  treated  ? 

Cut  off  the  cord  at  the  point  where  it  is  ligated,  and  squeeze  out 
Wharton's  jelly,  and  then  apply  a  new  ligature.  Then  dust  over 
the  cord  some  iodoform  or  salicylic  acid,  and  secure  it  by  a  few 
turns  of  a  muslin  bandage.  Lusk  simply  wraps  the  cord  in  absor- 
bent cotton  and  places  it  on  the  left  side,  where  it  is  retained  in 
place  by  the  binder. 

Describe  the  method  of  washing  the  child. 

The  vernix  caseosa  should  be  softened  and  removed  with  the 


LABOR.  143 

yelk  of  an  egg  or  some  oily  substance,  such  as  lard,  vaseline, 
sweet  oil,  etc.  The  bath  should  be  about  98°;  a  fine  soap 
should  be  used  to  cleanse  the  child,  as  the  more  common  article 
is  apt  to  irritate  the  skin.  After  bathing,  the  child  should  be 
gently  dried,  and  the  "  belly-band  "  applied. 

What  precautions  should  be  taken  in  the  application  of 
the  "belly-band"? 

The  bandage  around  the  body  of  the  child  should  be  loose  when 
first  applied ;  if  this  precaution  is  not  taken,  it  may  become  too 
tight  in  the  course  of  a  few  hours,  on  account  of  the  increase  in 
the  pulmonary  capacity. 

Asphyxia  Neonatorum. 

How  many  forms  of  asphyxia  occur  ? 
Two  ;  asphyxia  livida  and  pallida. 

What  are  the  symptoms  of  asphyxia  livida? 

The  surface  of  the  child  is  cyanotic;  the  face  is  swollen  and  of  a 
dusky  hue;  the  conjunctiva  is  injected,  and  the  eyeballs  protrude. 
The  muscles  are  somewhat  rigid,  and  the  pulsations  in  the  cord  are 
strong  and  slow.     Irritation  of  the  skin  causes  reflex  movements. 

What  are  the  symptoms  of  asphyxia  pallida  ? 

The  skin  is  anaemic ;  the  surface  cold ;  the  muscular  system  is 
relaxed,  and  the  extremities  and  lower  jaw  hang  loosely  down ; 
irritation  of  the  skin  is  not  followed  by  reflex  movements.  The 
pulsations  in  the  cord  are  almost  imperceptible. 

What  is  the  treatment  in  asphyxia  pallida  ? 

In  this  form  of  asphyxia  the  child  requires  all  the  blood  it  can 
get;  to  accomplish  this  object  press  the  blood  from  the  cord  toward 
the  umbilicus.  Next  tie  the  cord  and  cut  it.  The  first  step  toward 
resuscitation  is  to  remove  any  mucus  or  fluid  which  may  have 
collected  in  the  air-passages.  For  this  purpose  the  little  finger 
answers  very  well.  Lusk  advises  the  removal  of  the  fluid  by  aspi- 
ration with  an  elastic  catheter  (No.  6  or  8)  passed  through  the 
glottis.  After  the  air-passages  have  been  cleared  of  fluid,  place 
the  child  in  a  basin  of  hot  water  and  dash  cold  water  upon  the 


144  ESSENTIALS    OF    OBSTETRICS. 

epigastrium.  Then  remove  the  child  from  the  bath  and  make 
friction  over  the  chest,  spine,  and  the  soles  of  the  feet.  If  these 
means  fail,  after  trying  them  for  ten  minutes,  resort  to  artificial 
respiration. 

What  is  the  treatment  in  asphyxia  livida? 

Cut  the  cord  and  allow  two  or  three  drachms  of  blood  to  escape 
before  tying.  The  methods  already  described  in  the  treatment  of 
asphyxia  pallida  should  be  tried  before  resorting  to  artificial 
respiration. 

What  are  the  methods  of  performing  artificial  respiration? 

1.  Silvester's  method;  2.  Schultze's  method;  3.  Insufflation 
through  a  tube ;  4.  Mouth-to-mouth  insufflation. 

Describe  these  methods. 

Silvester^s  Method. — The  child  is  placed  upon  its  back  with  the 
shoulders  slightly  raised.  It  should  be  wrapped  in  warm  clothing. 
Now  grasp  the  arms  above  the  elbows  and  bring  them  quickly  up- 
ward by  the  sides  of  the  head,  at  the  same  time  everting  them; 
then  bring  them  down  again  against  the  sides  of  the  chest  and 
make  firm  pressure.  These  movements  should  be  repeated  at  in- 
tervals corresponding  with  normal  respirations. 

"Schultze's  Method. — The  accoucheur,  standing  with  the  body 
slightly  bent  forward,  the  legs  moderately  separated,  the  arms  ex- 
tended toward  the  ground,  seizes  the  infant  by  the  index  fingers 
passed  from  behind  forward  into  the  axilla.  The  thumbs  rest 
gently  over  the  clavicles,  and  the  remaining  fingers  are  applied 
against  the  posterior  surface  of  the  clavicle  in  the  direction  from 
above  downward. 

"  The  infant's  head  is  supported  against  the  wrists.  This  position 
is  that  of  inspiration  (Fig.  4).  The  accoucheur,  thus  holding  it, 
suddenly  throws  the  infant  forward  and  upward.  When  the  ac- 
coucheur's arms  are  a  trifle  above  the  horizontal  line,  the  motion  is 
gently  stopped,  so  as  not  to  jerk  the  child,  and  the  foetal  lumbar 
spine  is  flexed,  the  abdomen  being  forcibly  compressed  by  the 
weight  of  the  pelvic  extremity  (Fig.  5).  .  .  .  The  position  of  the 
child  is  now  gently  changed  to  that  which  it  occupied  at  the 
outset." 


LABOK. 


145 


Insufflation  through  a  Tube. — The  best  instrument  to  use  is 
Depaul's  modification  of  Chaussier's  tube.  First  clear  the  air- 
passages  of  mucus  and  then  guide  the  tube  into  the  larynx  by  the 
finger.    Before  blowing  into  the  tube  the  nostrils  must  be  closed 


Fm.  4. 


Fig.  5. 


Inspiration. 


Schultze's  method. 


Expiration. 


and  the  mouth  pressed  around  the  instrument.  Insufflate  from  ten 
to  fifteen  times  a  minute,  using  "  some  force."  Expiration  is  rein- 
stated by  pressing  upon  the  chest.  This  process  must  be  continued 
in  some  cases  for  an  hour  or  more. 

Mouth-to-mouth  Insufflation. — Wipe  the  mouth  of  the  child  and 
ilear  away  the  mucus  from  the  air-passages.    Then  the  accouch- 

10 


146  ESSENTIALS    OF    OBSTETRICS. 

eur,  frfter  taking  a  full  inspiration,  places  his  mouth  to  that  of  the 
child,  and  expires  with  some  force  into  its  air-passages.  Expira- 
tion is  assisted  in  the  child  by  pressure  upon  its  chest  and  stomach. 
During  the  act  of  inspiration  it  is  unnecessary  to  close  the  child's 
nostrils. 

"What  is  gavage? 

Gavage  is  the  name  given  to  a  method  of  feeding  new-born  infants 
who  are  prematurely  delivered  or  who  are  poorly  nourished. 
"  Take  a  piece  of  gutta-percha  tubing  about  the  size  of  a  No.  14 
or  15  French  catheter.  This  is  fixed  on  one  of  the  breast  shields 
in  common  use  for  sore  nipples.  The  child  is  placed  on  the  knee 
of  the  nurse,  with  the  head  slightly  raised.  The  sound  is  moist- 
ened with  milk,  and  introduced  at  the  base  of  the  tongue ;  the 
child,  by  a  reflex  act  of  deglutition,  will  generally  draw  it  as  far  as 
the  entrance  to  the  oesophagus  ;  if  not,  it  is  gently  conducted  there 
until  fifteen  centimetres  of  the  sound  are  introduced.  Pinch  the 
sound  between  two  fingers,  pour  into  the  cupula  two  or  three  table- 
spoonfuls  of  milk,  and  relax  pressure  until  it  flows  gently  into  the 
stomach.  The  sound  must  be  taken  out  gently  and  quickly,  and 
the  infant  placed  in  the  warm  cradle  or  couveuse.  The  apparatus 
must  be  washed  in  a  solution  of  boric  acid  and  pure  water.  The 
quantity  of  milk  given  to  the  weakest  infants  is  eight  grammes 
every  hour." 

By  this  system  children  of  six  months  have  been  saved. 

Occipito-posterior  Positions. 

How  is  an  occipito-posterior  position  managed  ? 

Make  direct  pressure  upon  the  occiput.  The  occiput  rotates 
posteriorly  because  it  meets  with  too  great  resistance ;  therefore, 
by  preventing  the  descent  of  the  forehead,  we  at  the  same  time 
indirectly  lessen  this  resistance. 

Face  Presentations. 

Should  an  attempt  be  made  to  substitute  the  vertex  for  a 
face  ? 

No. 


LABOR.  147 

How  should  a  delay  in  the  anterior  rotation  of  the  chin  be 
managed  ? 

Parvin  advises  making  direct  pressure  upon  the  forehead.  Pen- 
rose makes  pressure  upon  the  posterior  cheek  with  the  hand,  or 
forceps  blade.  If  the  chin  rotates  into  the  sacral  cavity,  craniotomy 
must  be  performed. 

What  precaution  should  be  taken  in  the  management  of 
face  presentations  ? 

Care  should  be  exercised  not  to  injure  the  eyes  during  vaginal 
examination.  Should  any  delay  occur  during  the  birth  of  the 
head,  it  may  be  necessary  to  assist  the  delivery,  as  the  throat  being 
pressed  against  the  symphysis,  may  endanger  the  life  of  the  child. 
The  family  should  be  informed  of  the  probable  distortion  of  the 
face,  at  the  same  time  assuring  them  of  its  spontaneous  disappear- 
ance in  the  course  of  a  few  days. 

Broio  Presentations. 

What  is  the  management  of  presentations  of  the  brow  ? 

The  case  should  be  left  to  Nature.  Eventually  the  presentation 
becomes  either  a  vertex  or  face.  If  the  pelvis  be  roomy  and  the 
head  small,  spontaneous  delivery  may  occur  in  a  brow  presenta- 
tion. If  a  brow  presentation  does  not  change  into  a  vertex  or  face, 
allow  the  labor  to  continue  as  long  as  the  mother  is  in  no  danger 
and  then  apply  the  forceps.  If  the  chin  becomes  fixed  in  a  pos- 
terior position,  try  to  bring  down  the  occiput  and  produce  a  vertex 
presentation  ;  failing  in  this,  craniotomy  must  be  performed. 

How  should  pelvic  presentations  be  managed  ? 

Ancesthesia. — The  anaesthesia  should  be  obstetric,  not  surgical, 
as  the  patient  must  employ  both  the  voluntary  and  involuntary 
forces  of  expulsion. 

Membranes. — Preserve  the  membranes  as  long  as  possible.  Have 
the  patient  lying  down  during  the  first  stage  of  labor;  place  her 
on  her  side,  and  instruct  her  not  to  bear  down.  When  the  mem- 
branes become  elongated,  make  counter-pressure  by  means  of  a 
Barnes's  dilator  inserted  into  the  vagina. 

Delivery  of  Breech. — The  perineum  should  be  supported.  The 
patient  should  be  told  to  bear  down  during  the  contractions.     As 


148  ESSENTIALS    OF    OBSTETRICS. 

the  breech  is  born  it  should  be  received  in  the  palm  of  the  hand 
and  carried  upward. 

Umbilical  Cord.  — As  soon  as  the  cord  can  be  reached,  it  should 
be  drawn  down  and  placed  to  the  side  of  the  sacral  cavity.  If  the 
cord  be  coiled  around  one  of  the  thighs  it  should  be  slipped  over 
it.  The  pulsations  of  the  cord  should  be  felt  from  time  to  time, 
and  any  indication  of  failure  of  the  circulation  must  be  met  by 
artificial  extraction. 

Delivery  of  Body. — The  breech  is  now  supported  by  one  hand, 
while  with  the  other  pressure  is  made  over  the  fundus  of  the  uterus, 
the  patient  at  the  same  time  aiding  the  delivery  by  making  bear- 
ing-down efforts.  During  the  delivery  of  the  arm  and  shoulders 
the  hips  should  be  raised  and  the  perineum  supported.  Traction 
should  not  be  made  upon  the  trunk,  as  it  may  cause  displacement 
of  the  arms  or  extension  of  the  head.  If  the  former  accident 
occurs,  bring  down  the  posterior  arm  first.  This  may  usually  be 
accomplished  by  passing  one  or  two  fingers  up  to  the  elbow  and 
drawing  the  forearm  over  the  chest.  If  the  elbow  cannot  be 
reached,  then  make  pressure  directly  upon  the  upper  part  of  the 
arm. 

Delivery  of  Head. — The  occiput  rotates  anteriorly,  while  the 
face  occupies  the  sacral  cavity.  As  soon  as  rotation  has  taken 
place  the  body  of  the  child  should  be  raised  toward  the  mother's 
abdomen;  at  the  same  time  keeping  up  flexion  of  the  head  by 
pressure  upon  the  forehead  with  the  fingers,  either  placed  on  the 
perineum  or  inserted  into  the  rectum.  If  any  delay  occurs  in  the 
delivery  of  the  head,  the  patient  should  make  bearing-down  efforts ; 
at  the  same  time  the  accoucheur  should  exert  supra-pubic  pressure 
and  frictions  over  the  uterus.  The  accoucheur  should  always  have 
the  forceps  at  hand  in  every  case  of  head-last  labor.  Delay  in  the 
expulsion  of  the  head  may  be  caused,  in  some  cases,  by  the  os 
uteri  contracting  around  the  neck  of  the  child.  This  condition 
may  be  overcome  by  dilatation  of  the  cervix  with  the  fingers,  or 
by  incisions. 

Posterior  Rotation  of  the  Occiput. — The  mechanism  of  labor  in 
a  posterior  rotation  of  the  occiput  has  already  been  referred  to. 


LABOR.  149 

What  are  the  methods  advised  for  extraction  in  a  pelvic 
presentation  when  the  foetus  is  doubled? 

1.  Hooking  the  finger  over  the  groin. 

2.  The  application  of  the  forceps ;  Tarnier's  instrument  should 
be  preferred. 

3.  Traction  with  a  blunt  hook.  The  instrument  should  be  in- 
serted between  the  thighs  with  its  point  toward  the  side  of  the 
mother's  pelvis.    As  a  rule,  it  is  applied  over  the  anterior  thigh. 

4.  Bring  down  a  foot.  By  this  method  the  wedge  is  decom- 
posed. 

5.  The  use  of  the  fillet. 

What  is  the  management  of  labor  in  multiple  pregnancies  ? 

If  the  presentation  of  the  first  child  be  favorable,  rupture  the 
membranes  after  the  cervix  is  fully  dilated.  The  cord  of  the  first 
child  should  have  a  second  ligature  applied  to  it.  During  the  de- 
livery of  the  second  child,  keep  the  hand  firmly  applied  to  the 
uterus.  The  delivery  of  the  placenta  should  be  effected  as  in 
normal  labor.  In  the  majority  of  cases  the  second  child  is  deliv- 
ered in  about  twenty  minutes  after  the  first.  If  the  placenta  re- 
mains in  the  uterus  after  the  birth  of  the  first  child,  the  accoucheur 
must  not  leave  the  patient  until  the  second  foetus  is  delivered.  On 
the  other  hand,  however,  if  the  first  child  be  feeble  or  dead,  and 
the  placenta  comes  away  with  it,  leave  the  case  to  nature,  as  the 
second  child,  under  these  circumstances,  may  go  to  term.  The 
after-treatment  of  plural  deliveries  is  the  same  as  in  normal  births ; 
greater  precautions,  however,  must  be  taken  to  guard  against  post- 
partum hemorrhage. 

How  should  cases  of  difficult  delivery  of  the  shoulders  be 
managed  in  head-first  labors  ? 

1.  Instruct  the  patient  to  make  bearing-down  efforts  ;  the  ac- 
coucheur at  the  same  time  pressing  upon  and  making  friction  over 
the  uterus  through  the  abdominal  wall ;  or 

2.  Apply  the  hands  to  the  sides  of  the  head  and  make  traction 
upward  toward  the  pubes ;  or 

3.  Make  traction  on  the  posterior  shoulder  with  the  finger 
hooked  into  the  axilla  ;  or 


150  ESSENTIALS    OF    OBSTETKICS. 

4.  Make  traction  with  the  fingers  in  each  axilla ;  or 

5.  Push  the  anterior  shoulder  back  beyond  the  symphysis ;  this 
brings  the  posterior  shoulder  to  the  edge  of  the  perineum.  Now 
carry  the  head  backward,  and  the  anterior  shoulder  will  again 
come  beyond  the  arch  of  the  pubes,  and  delivery  be  easily  effected ; 
or 

6.  Make  traction  with  a  blunt  hook  introduced  into  the  axilla 
of  the  posterior  shoulder. 

Antisepsis. 

Labor  and  Puerperal  State. 

"What  precautions  should  be  taken  against  septic  infection 
during  labor  and  in  the  puerperal  state  ? 

1.  The  Lying-in  Boom. — This  should  be  well  ventilated  and  free 
from  septic  germs,  especially  those  of  scarlet  fever,  erysipelas,  and 
diphtheria.  Cancer  of  the  uterus  in  an  advanced  stage  and  all 
forms  of  suppurative  diseases  are  especially  liable  to  cause  septi- 
caemia. All  evacuations  from  the  bladder  and  bowels,  and  soiled 
clothing,  should  be  immediately  removed  from  the  room. 

2.  The  Nurse. — The  nurse  should  be  free  from  skin  diseases, 
especially  of  a  suppurative  nature.  She  should  not  have  attended 
recently,  patients  suffering  with  scarlet  fever,  diphtheria,  ery- 
sipelas, suppurative  diseases,  or  puerperal  septicaemia. 

3.  Preparation  of  the  Hands. — The  physician  should  carefully 
disinfect  his  hands  before  making  an  examination  per  vaginam  in 
the  following  way :  Wash  them  thoroughly  with  warm  water  and 
soap,  using  a  nail-brush,  after  which  soak  them  in  a  solution  of 
corrosive  sublimate,  1  to  1000.  The  same  precautions  apply  to 
the  nurse. 

4.  Instruments. — All  instruments  should  be  sterilized  by  plac- 
ing them  in  boiling  water. 

5.  The  Patient. — At  the  beginning  of  labor  the  patient  should 
be  given  a  warm  bath,  and  the  external  genital  organs  should  be 
thoroughly  washed  with  a  solution  of  corrosive  sublimate,  1  to 
2000.     If  the  labor  be  prolonged,  a  warm  vaginal  injection  of  cor- 


LABOR.  151 

rosive  sublimate,  1  to  3000,  should  also  be  given.  After  using  an 
antiseptic  vaginal  injection  always  wash  out  the  vagina  with  warm 
distilled  water.  Antiseptic  vaginal  injections  are  especially  indi- 
cated in  the  interests  of  the  child  when  the  mother  is  suffering 
with  gonorrhoea  or  other  purulent  discharges,  as  a  prophylactic 
measure  against  the  occurrence  of  ophthalmia  neonatorum. 

After  delivery  the  vagina  should  be  Vr'ashed  out  with  the  anti- 
septic solution  and  the  external  organs  cleansed  in  a  similar 
manner.  The  external  organs  should  be  washed  twice  daily  with 
a  solution  of  corrosive  sublimate,  1  to  2000. 

The  vulva  should  be  protected  with  a  napkin  which  has  been 
previously  dipped  in  a  warm  solution  of  corrosive  sublimate,  1  to 
2000,  and  squeezed  out.  Only  one  antiseptic  vaginal  injection  is 
indicated  after  labor,  unless  the  soft  parts  have  been  torn,  when 
the  vagina  should  be  irrigated  twice  daily  and  the  tears,  if  slight, 
dusted  with  iodoform,  but,  if  serious,  sutures  must  be  introduced. 


The  Pathology  of  Labor. 

Precipitate  Labor. 

What  are  the  causes  of  precipitate  labor  ? 

1.  Excessive  force  and  frequency  of  the  uterine  contractions; 
and 

2.  Relaxation  of  the  soft  parts. 

What  is  the  prognosis? 

Favorable  if  proper  precautions  are  taken,  if  the  presentation 
of  the  foetus  is  normal,  and  there  is  no  obstruction  in  the  birth 
canal. 

What  are  the  dangers  ? 

Laceration  of  the  soft  parts  (cervix  and  perineum);  subsequent 
relaxation  of  the  uterus  and  post-partum  hemorrhage ;  or  the  foetus 
may  die  of  asphyxia,  from  the  continuous  compression.  If  de- 
livery occurs  while  the  Avoman  is  standing,  the  child  may  be  in- 
jured by  the  fall,  the  placenta  may  be  detached,  or  inversion  of 
the  uterus  occur.  The  bearing-down  efforts,  if  excessive,  may  pro- 
duce a  subcutaneous  emphysema  of  the  chest,  neck,  and  face. 


162  ESSENTIALS    OF    OBSTETRICS. 

What  is  the  treatment  ? 

The  woman  should  be  in  bed  and  placed  upon  her  side,  and  all 
bearing-down  efforts  should  be  forbidden.  Inhalations  of  ether 
or  chloroform  are  given,  if  necessary,  to  the  extent  of  complete 
anaesthesia.  Chloral,  or  hypodermatic  injections  of  morphia,  are 
also  of  service.  Should  emphysema  occur,  uterine  efforts  alone, 
or  the  forceps  must  terminate  the  labor.  The  condition  disap- 
pears spontaneously  in  a  few  days  after  delivery. 

Prolong-ed  Labor. 

What  are  the  causes  of  prolonged  labor  ? 

1.  Pelvic  deformity. 

2.  Neoplasms  encroaching  upon  the  birth-canal. 
8.  Mal-presentations  and  positions  of  the  fcetus. 

4.  Rigidity  of  the  soft  parts. 

5.  Malpositions  of  the  uterus. 

6.  Deficiency  of  uterine  force  due  to 

a.  General  debility. 

h.  Premature  rupture  of  the  membranes. 

c.  Frequent  child-bearing. 

d.  Age  of  patient. 

e.  Disorders  of  the  intestines. 

/.   Over-distention  of  the  uterus ;  for  example,  hydramnios 

or  plural  pregnancies. 
g.  Deficient  uterine  innervation. 
h.  Full  bladder  or  rectum. 
i.   Mental  infiuences. 

7.  Weak  bearing-down  efforts  due  to 

a.  General  debility. 

6.  Great  suffering  associated  with  the  uterine  contractions. 

c.  The  patient  may  be  narcotized. 

What  is  the  prognosis  ? 

The  prognosis  depends  upon  the  stage  of  labor  in  which  the 
delay  occurs;  upon  the  cause;  and  upon  the  condition  of  the 
mother  and  child. 

First  Stage  of  Labor . — 1.  Child.    There  is  no  danger  to  the  child 


LABOR.  153 

as  long  as  the  membranes  remain  unruptured.  Under  these  con- 
ditions labor  may  continue  for  any  length  of  time,  even  days. 

2.  Mother.  As  a  rule,  there  is  no  immediate  danger  to  the 
mother.  On  the  other  hand,  however,  if  the  labor  be  extended 
to  any  great  length  of  time,  the  patient  may  suffer  seriously  from 
exhaustion,  loss  of  sleep  and  appetite. 

Second  Stage.— 1.  Child.  Delay  during  this  stage  endangers  the 
child's  life  by  asphyxia.  Charpentier  advises  delivery  with  the 
forceps  when  the  head  has  been  arrested  for  an  hour  or  two  after 
reaching  the  pelvic  floor. 

2.  Mother.  The  dangers  to  the  mother  are  the  result  of  pressure 
upon  the  soft  parts,  causing  sloughing,  followed  by  fistulse  or  septic 
infection.  Again,  the  exhaustion  may  be  so  great  as  to  endanger 
life,  or,  at  least,  to  delay  complete  recovery  for  a  long  period  of 
time. 

Third  Stage. — Hemorrhage  invariably  results  in  this  stage  if  the 
uterus  is  in  a  condition  of  inertia. 

The  prognosis  of  delayed  labor  due  to  pelvic  deformity,  neo- 
plasms, mal-presentations  and  positions,  and  displacements  of  the 
uterus  is  considered  elsewhere  under  separate  headings. 

How  is  delayed  labor  treated? 

It  is  hardly  necessary  to  state  that  the  treatment  depends  upon 
the  cause.  The  treatment  of  labor  in  pelvic  deformity,  neoplasms, 
mal-presentations  and  positions,  and  displacements  of  the  uterus 
is  considered  elsewhere. 

1.  Rigidity  of  the  Cervix. — Chloral  is  the  drug  which  will  do 
the  most  service  in  this  condition.  In  addition,  if  necessary,  warm 
baths  and  injection  of  warm  water  into  the  vagina  may  also  be 
employed.  If,  as  is  sometimes  the  case  in  old  primiparse,  the 
rigidity  presents  a  permanent  obstacle  to  delivery,  artificial  dilata- 
tion of  the  cervix  must  be  resorted  to  ;  Schroeder  advised  incisions 
to  be  made. 

In  cases  of  obliteration  of  the  external  os  due  to  a  superficial  in- 
flammation, the  difficulty  may  be  overcome  by  pressing  upon  the 
situation  of  the  os  with  a  finger  during  a  uterine  contraction,  or  by 
the  uterine  sound,  or  dilator. 

If  the  obliteration  of  the  os  be  due  to  cicatricial  tissue.  Nature, 


154  ESSENTIALS    OF    OBSTETRICS. 

as  a  rule,  will  overcome  the  difficulty  assisted  by  artificial  dilatation; 
it  may  be  necessary,  finally,  to  make  incisions. 

When  the  cervix  is  unable  to  retract  over  the  presenting  part, 
on  account  of  adhesions  between  the  membranes  and  uterine  walls, 
separation  may  be  effected  by  means  of  the  finger  or  a  soft  catheter. 
Puncturing  the  membranes  is  also  a  good  plan  of  treatment  under 
these  circumstances. 

2.  Deficiency  of  Uterine  Force. — 

a.  Over-distention  of  the  uterus.  Rupture  the  membranes  and 
allow  the  liquor  amnii  to  escape.  If  the  over-distention 
be  due  to  polyhydramnios,  the  precautions  already  re- 
ferred to  should  be  taken. 
h.  Full  bladder  and  rectum.  The  indication  is  to  empty  these 
organs ;  the  former  with  a  catheter,  while  the  latter  should 
be  unloaded  by  a  large  enema. 

c.  Deficient  uterine  innervation.     Under  these   circumstances 

the  uterine  contractions  are  increased  by  a  change  of  posi- 
tion, walking  or  sitting,  stimulating  rectal  injections, 
vaginal  douches  of  hot  water,  and  hot  drinks,  such  as  tea 
or  lemonade. 

d.  Deficient  uterine  force,  when  due  to  premature  rupture  of 

the  membranes,  frequent  childbearing,  age,  mental  emo- 
tions, and  general  debility,  is,  of  course,  treated  upon 
general  principles,  as  the  cause  cannot  be  removed.  Under 
these  circumstances  the  treatment  is  essentially  directed 
against  the  condition  of  uterine  inertia,  without  refer- 
ence to  the  cause.  The  treatment  of  weak  labor  j)ains 
will  be  considered  later  on. 

e.  Great  suffering  associated  with  ineffective  labor  pains.     If  this 

condition  occurs  in  the  first  stage,  give  chloral.  Thirty 
grains  should  be  given  at  once  by  the  rectum  and  repeated 
in  one-half  hour.  If  administered  by  the  mouth,  give 
fifteen  grains  every  quarter  of  an  hour,  until  four  doses 
have  been  taken. 
/.  Temporary  exhaustion.  Occasionally  in  the  first  stage  of 
labor  the  patient  becomes  restless,  and  exhausted  on 
account  of  the  pains  being  weak  and  ineffective ;  the  in- 
dication is  to  create  a  temporary  rest.  Under  these  con- 
ditions give  either  chloral  or  morphia. 


LABOR.  155 

What  means  are  employed  to  stimulate  weak  and  ineffec- 
tive uterine  contractions  ? 

1.  Drugs. — 

a.  Quinine.  It  should  be  given  in  a  dose  of  from  fifteen  to 
twenty  grains.  It  will  not  excite  uterine  contractions,  but 
stimulates  them  when  present  by  its  general  tonic  effect 
upon  the  nervous  system.  It  also  guards  against  post- 
partum hemorrhage,  by  promoting  permanent  tonic  con- 
tractions of  the  uterus.  In  cases  where  the  lochial  dis- 
charges have  been  excessive,  it  diminishes  the  quantity ; 
it  also,,  as  a  rule,  lessens  after-pains. 
h.  Ergot.  It  may  be  given  either  by  the  mouth,  in  the  form 
of  the  fluid  extract,  or  hypodermatically,  in  which  case 
ergotine  should  be  employed  dissolved  in  water.  The 
dose  of  the  fluid  extract  should  not  exceed  ten  minims, 
and  should  be  given  every  fifteen  minutes  until  uterine 
contractions  become  more  energetic.  One  grain  of  ergo- 
tine represents  five  minims  of  the  fluid  extract;  given 
hypodermatically,  the  dose  would  be  two  grains. 

The  following  rules  govern  the  administration  of  the 
drug  in  labor : 

It  must  not  be  employed  in  the  first  stage ;  labor  must 
be  advanced  and  the  os  fully  dilated ;  the  presentation 
and  position  of  the  foetus  must  be  favorable ;  the  birth- 
canal  must  be  normal,  and  the  drug  must  be  given  in 
small  doses. 

2.  The  Faradic  Current. — Place  an  electrode  on  either  side  of  the 
abdomen  over  the  uterus,  and  continue  the  application  for  fifteen 
minutes. 

3.  Manual  Pressure.  —  This  may  be  applied  with  the  patient 
either  upon  the  back  or  upon  the  side.  In  the  former  position, 
which  is  the  best,  place  the  hands  over  the  sides  of  the  fundus  and 
body  of  the  uterus,  and  during  a  uterine  contraction  make  pressure 
downward  and  backward  toward  the  superior  strait.  In  the  latter 
position,  the  left  hand,  if  the  patient  is  upon  the  left  side,  is  ap- 
plied over  the  fundus  and  pressure  made  in  the  same  direction. 
Manual  pressure  is  contra-indicated  if  the  uterus  is  unusually 
tender,  or   in   a  state  of  tonic   contraction   due  to   exhaustion. 


156  ESSENTIALS    OF    OESTETEICS. 

Again,  tlie  birth- canal  must  be  normal  in  size  and  the  presenta- 
tion and  position  of  the  foetus  favorable. 

When  should  the  forceps  be  applied  in  a  labor  delayed  by 
weak  uterine  contractions? 
After  the  head  has  descended  into  the  pelvic  cavity,  if  its  pro- 
gress be  delayed  for  two  hours  we  apply  the  forceps. 

Dystocia  due  to  ttie  FcBtus. 

Dorsal  Displacement  of  the  Ar.m. 

How  is  a  dorsal  displacement  of  the  arm  managed  in  a 
head-first  or  in  a  head-last  labor? 

Head-first. — The  diagnosis  of  this  displacement  is  difficult,  as  the 
presentation  is  too  high  up  to  be  reached  by  the  examining  finger. 
If  in  a  given  case,  the  uterine  contractions  being  strong  and  the 
pelvis  of  normal  size,  the  head  fails  to  make  any  progress  after  a 
certain  length  of  time,  place  the  patient  under  an  anaesthetic  and 
complete  the  diagnosis.  The  arm  may  then  be  brought  down, 
thus  making  a  hand-and-head  presentation,  or — and  this  is  the 
more  eiFective  plan — podalic  version  may  be  performed. 

Head-last. — The  diagnosis  of  this  displacement  is  easier  in  a 
head-last  labor.  The  arm  may  generally  be  liberated  by  carrying 
the  trunk  of  the  child  well  backward,  and  then  introducing  the 
finger  behind  the  symphysis  and  over  the  shoulder;  then  press 
the  elbow  downward  and  forward.  Another  plan  is  to  rotate  "the 
child  in  the  opposite  direction  to  that  rotation  which  caused  the 
difficulty."  If  it  is  found  impossible  to  free  the  arm,  embryotomy 
may  be  necessary. 

Excessive  Development  of  the  Foetus. 

Premature  Ossification. 

How  is  the  delivery  of  the  foetus  managed  when  the  bones 
of  the  head  are  prematurely  ossified  ? 
The  indications  are  the  same  as  those  which  guide  us  in  all 
cases  of  disproportion  between  the  size  of  the  foetus  and  the  pelvis. 


LABOR.  157 

Delivery  is  usually  accomplished  with  the  forceps.     If  it  is  impos- 
sible by  this  means,  embryotomy  must  be  resorted  to. 

Large  Size  of  the  Body. 

How  is  the  delivery  managed  when  the  trunk  of  the  foetus 
is  excessively  developed  ? 
This  is  very  rarely  a  cause  of  dystocia,  for  after  the  head  is  born 
the  body,  which  is  compressible,  as  a  rule,  follows.  If  the  shoul- 
ders cannot  be  delivered,  by  means  already  described,  embryotomy 
must  be  performed. 

Large  Size  of  the  Foetal  Head. 

How  is  delivery  managed  when  the  foetal  head  is  excess- 
ively developed? 

The  indications  in  the  management  of  labor  are  the  same  as 
those  already  described  when  the  bones  are  prematurely  ossified. 

Is  the  induction  of  premature  labor  indicated  when  chil- 
dren of  previous  pregnancies  have  been  stiU-born 
from  excessive  development  ? 
Yes.    This  question  will  be  more  fully  discussed  in  the  chapter 

on  induction  of  premature  labor. 

Hydrocephalus. 

What  is  hydrocephalus  ? 

A  serous  effusion  in  the  cranial  cavity. 

What  is  its  etiology  ? 

The  essential  cause  is  unknown.  The  following  are  considered 
as  causes:  Cretinism,  alcoholism,  syphilis,  impoverished  condition 
of  the  mother's  blood,  and  marriages  of  consanguinity. 

What  is  the  diagnosis  ? 

Head-first  Labor. — 

a.  Palpation.     The  head  will  be  felt  larger  and  higher  up  than 

normal. 

b.  Auscultation.     The  heart  sounds  will  be  heard  at  or  above 

the  transverse  line. 

c.  Abdomino-vaginal  touch.     Fluctuation  can  be  felt. 


158  ESSENTIALS    OF    OBSTETRICS. 

d.  Indigation.    The  examining  finger  feels  a  fluctuating  tumor, 

wMch  becomes  tense  during  a  uterine  contraction.  During 

a  pain  the  scalp  remains  smooth  and  there  is  no  overriding 

of  the  bones.     The  cranial  bones  are  found  less  firm,  and 

more  flexible;  the  size  of  the  presenting  part  is  larger 

than  normal;  the  shape  of  the  head  less  convex,   and 

the  sutures  and  fontanelles  are  further  apart  and  more 

open. 

Head-last  Labor. — In  most  cases  the  diagnosis  is  not  made  until 

after  the  trunk  is  born,  and  then  the  arrest  of  the  after-coming 

head  necessitates  an  examination  to  determine  the  cause  of  delay, 

when  the  condition  may  be  recognized. 

a.  Palpation.  The  uterus  and  abdomen  are  found  to  be  much 
larger  than  would  be  the  case  after  the  expulsion  of  the 
body  of  the  child  when  the  head  is  normal  in  size.  The 
uterus  also  contains  a  large  round  body. 
h.  Indigation.  The  examining  finger  coming  in  contact  with 
the  occipital  bone  recognizes  the  peculiarities  already 
referred  to.  If  the  arms  are  extended  and  an  effort  be 
made  to  bring  them  down,  they  will  be  found  much  higher 
in  the  pelvis. 

Does  hydrocephalus  interfere  with  the  accommodation  of 
the  foetus? 
Yes.     There  is  a  larger  proportion  of  pelvic  and  shoulder  pre- 
sentations. 

What  is  the  foetal  and  maternal  mortality  ? 

If  the  life  of  the  child  is  not  sacrificed  during  labor,  it,  as  a  rule, 
dies  early  in  infancy.  The  great  danger  to  the  mother  is  from  rup- 
ture of  the  uterus ;  sloughing  of  the  soft  parts  and  exhaustion  may 
also  endanger  her  life.  If  hydrocephalus  be  recognized  early  in 
the  labor,  the  maternal  prognosis  is  favorable.  Parvin  teaches 
that  when  an  early  diagnosis  is  made  "recovery  would  probably 
be  the  rule,  and  very  few  exceptions  occur." 

"What  are  the  indications  in  treatment  ? 

Head-first  Labor. — If  labor  be  delayed,  puncture  the  head  and 
allow  the  fluid  to  escape.     Then  if  delivery  does  not  occur  spon- 


LABOR.  159 

taneously,  make  traction  with  the  cephalotribe,  cranioclast,  or 
forceps.  The  latter  instrument  must  be  used  with  great  care,  as  it 
is  very  liable  to  slip  when  traction  is  made.  Lusk  holds  that  the 
forceps  should  never  be  used.  Some  obstetricians,  after  punctur- 
ing the  head,  advise  podalic  version,  but  Parvin  teaches  that  the 
operation  is  unnecessary,  and  often  impossible. 

Head-last  Labor. — If,  after  making  a  moderate  amount  of  trac- 
tion and  at  the  same  time  pressing  upon  the  head  above  the  pubes, 
the  fostus  cannot  be  expelled,  puncture  must  be  resorted  to. 

If  the  head  is  too  high  up  in  the  pelvis  to  reach  with  an  instru- 
ment, open  the  spinal  canal  and  introduce  an  elastic  catheter  up 
into  the  brain.  The  opening  into  the  spinal  canal  should  be  made 
as  close  to  the  mother's  body  as  possible.  Some  authorities  de- 
truncate and  then  deliver  the  head. 

Monstrosities. 

How  are  monsters  divided  ? 

Into  1.  Single  monsters.  2.  Double  monsters.  3.  Parasite 
monsters. 

Name  and  describe  the  single  monsters. 

1.  EcTROMELic  Monsters  — Where  there  is  a  want  of  develop- 
ment, more  or  less  complete,  of  one  or  more  of  the  extremities. 

a.  Phocomelus.     Atrophy  of  the  arms  and  thighs,  but  normal 

development  of  the  hands  and  feet,  forearms  and  legs. 

b.  Hemimelus.     Normal  development  of  the  arms  and  thighs, 

but  atrophy  of  the  other  segments  of  the  limbs,  forearms 
and  hands,  legs  and  feet. 

c.  Ectromelus.     There  is  an  arrest  of  development  of  all  the 

segments,  the  extremities  being  mere  stumps. 

2.  Symelic  Monsters. — Where  there  is  a  fusion  of  the  extrem- 
ities in  the  median  line,  more  or  less  complete. 

a.  Symelus.     Where  the  fusion  is  not  complete,  the  extremities 

terminating  in  two  feet,  or  two  hands. 

b.  Uromelus.    Where  the  fusion   is  more  complete,   the  ex- 

tremities terminating  in  a  single  foot,  or  hand. 
0.  Sirenomelus.     The  extremities  terminate  in  a  point,  without 
hands,  or  feet. 


160  ESSENTIALS    OF    OBSTETRICS. 

3.  EXENCEPHALIC  MoNSTERS. — Where  there  is  a  malformation 
of  the  brain,  which  is  placed,  more  or  less,  outside  the  cranium; 
the  skull  itself  is  also  imperfectly  developed. 

a.  Notencephalus.     The  brain  is  almost  entirely  external  to  the 

cranial  cavity,  the  protrusion  being  situated  in  the  occipital 
region. 

b.  Proencephalus.     Where  the  brain  protrudes  through  a  fissure 

in  the  frontal  bone. 

c.  Podencephalus.     Where  the  brain  protrudes  through  a  fissure 

in  the  vault  of  the  skull ;  the  tumor  is  usually  peduncu- 
lated. 

d.  Hyperencephalus.      This  variety  of  monster  is  practically 

a  highly  exaggerated  example  of  podencephalus.  The 
superior  part  of  the  cranium  is  almost  entirely  absent,  and 
the  upper  part  of  the  occipital  bone  is  lacking.  The 
brain  is  placed  almost  entirely  outside  of  the  cranial 
cavity. 

e.  Iniencephalus.     Where  the  brain  protrudes  through  an  open- 

ing in  the  occipital  bone,  associated  with  spinal  fissure. 
This  monster  is  practically  a  notencephalic  foetus  plus  the 
spinal  fissure. 

/.  Exencephalus.  The  brain  protrudes  in  very  great  part  out- 
side of  the  cranial  cavity,  and  is  associated  with  vertebral 
fissure.  This  monster  is  practically  a  hyperencephalic 
fcetus  plus  the  spinal  fissure. 

g.  Pseudencephalus.  The  vault  of  the  cranium  is  absent  and 
the  brain  substance  is  almost  entirely  lacking.  Instead 
of  the  brain  there  is  a  vascular  tumor,  deep  red  in  color, 
which  is  derived  from  the  pia  mater.  "  The  head  has 
neither  forehead  nor  vertex,  is  sunk  between  the  shoulders 
and  surmounted  by  a  blood  tumor."    (Saint-Hilaire.) 

4.  Anencephalic  Monsters. — The  brain  and  cranial  vault  are 
absent.  These  monsters  are  practically  pseudencephalic  foetuses 
minus  the  vascular  tumor. 

a.  Derencephalus.  The  brain  and  cranial  vault  are  absent  and 
the  occipital  foramen  is  lacking.  There  is  also  an  arrest 
in  development  of  the  cervical  vertebras  and  also,  occa- 
sionally, of  the  upper  dorsal. 


LABOR.  161 

b.  Anencephalus.     There  is  an  arrest  in  development  of  the 
entire  vertebral  column,  which  is  open  and  forms  a  furrow. 
The  spinal  cord  is  absent.     This  variety  of  monster  is 
practically"  an   exaggerated  example  of  a  derencephalic 
foetus. 
5.  Cyclocephalic  Monsters, — Where  there  is  an  absence,  or 
more  or  less  atrophy,  of  the  nasal  apparatus ;    the  eyes  are  rudi- 
mentary and  approach  the  median  line,  occasionally  they  are  fused 
into  one. 

a.  Ethnocephalus.     The  nose  is  not  entirely  absent.     There  are 

two  incompletely  formed  nostrils,  or  only  one.     There  are 
two  eyes. 

b.  Cebocephalus.     The  nose  is  entirely  absent.     In  this,  as  in 

the  preceding  variety,  there  are  two  eyes. 

Fig.  6. 


Ehinocephalus. 

c.  Rhinocephalus.  The  nose  resembles  a  tube  or  trunk,  and 
the  eyes,  which  are  usually  fused  into  one,  occupy  the 
median  line,  and  are  situated  below.  The  nose,  as  a  rule, 
has  only  one  opening. 

11 


162  ESSENTIALS    OF    OBSTETRICS. 

d.  Cydocephalus.     Complete  atrophy  of  the  nose,  with  a  single 
eye  situated  in  the  median  line. 
6.  AcEPHALic  Monsters. — Where  there  is  a  complete  absence 
of  the  head. 

Name  and  describe  the  double  monsters. 

1.  Ensomphalic  Monsters. — "  These  foetuses  are  each  prac- 
tically complete  although  united  together,  and  are  able  to  accom- 
plish independently  almost  all  vital  functions.  Each  has  its  own 
umbilicus,  and,  during  intra-uterine  life,  its  umbilical  cord." 
(Saint-Hilaire.) 

a.  Pygopagus.      Where  the  buttocks,  or  backs   are  united. 

These  monsters  are  viable. 

b.  Metopagus.      They  are  united  by  their  heads,  forehead  to 

forehead,  vertex  to  vertex. 

c.  Cephalopagus.     The  twins  are  also  united  by  their  heads  as 

in  the  preceding  variety,  but  they  are  fused  vertex  to  fore- 
head, forehead  to  vertex. 

2.  MoNOMPHALic  Monsters. — "  These  are  characterized  by  the 
union  of  two  complete  individuals  at  a  common  umbilicus." 

a.  Ischiopagus.     Where  they  are  united  by  the  ischiee. 

h.  Xiphopagus.  Where  they  are  united  by  the  xiphoid  carti- 
lages or  epigastrium.  The  Siamese  twins  are  an  example 
of  this  variety. 

c.  Sternopagus.     Where  the  twins  are  united  by  the  sternums. 

d.  Ectopagus.     Where  there  is  a  fusion  of  the  two  chests.    The 

thoracic  walls  are  unequally  developed. 

e.  Hemipagus.     The  same  as  the  preceding  variety,  except  that 

the  union  extends  to  the  mouths,  which  have  a  single 
cavity. 

3.  Sycephalic  Monsters. — Where  there  is  an  intimate  fusion 
of  the  two  heads. 

a,  Janiceps.     One  large  head  with  two  faces,  looking  in  oppo- 

site directions.     A   common  thorax   and  four  superior 
extremities. 

b.  Miopes.       One  face  is  fully  developed,  while  the  other  is 

imperfect.      The  latter  consists  of  two  ears,  or  only  one, 
and  above  it  is  placed  a  single  eye,  more  or  less  imper- 


LABOK.  163 

fectly  developed.     As  in  the  preceding  variety,  each  face 
looks  in  opposite  direction. 
c.  Synotes.     This  monstrosity  is  an  exaggeration  of  the  pre- 
ceding one.     All  parts  of  the  face  are  absent,  except  the 
ears,  which  are  placed  very  near  one  another,  or  fused. 

4.  MoNOCEPHALic  Monsters. — This  variety  consists  of  a  head, 
without  any  exterior  trace  of  union,  surmounting  two  bodies, 
fused  in  a  more  or  less  intimate  manner,  and  for  a  greater  or  less 
extent. 

a.  Deradelphus.     The  bodies  are  united  above  and  separated 

below  the  umbilicus.  There  are  four  lower  and  three 
or  four  upper  extremities. 

b.  Thoradelphus.     The  same   as   the  preceding,  except  that 

there  are  only  two  upper  extremities. 

c.  Meadelphus.     The  body  is  united  above  the  umbilicus,  and 

below  it  as  far  as  the  pelvis.  There  are  four  lower  and 
two  upper  extremities. 

d.  Synadelphus.     The  same  as  the  preceding,  except  that  there 

is  a  single  pelvis.  There  are,  also,  four  upper  and  four 
lower  extremities. 

5.  Sysomic  Monsters.  —  Where  there  is  more  or  less  com- 
plete union  of  the  two  bodies,  while  the  two  heads  remain 
separate. 

a.  Psodymus.     There  are  two  thoracic  cavities  and  two  heads. 

The  abdominal  and  pelvic  cavities  are  united.  There  are 
two  lower  extremities,  but  occasionally  a  third  rudimentary 
one  is  present. 

b.  Xyphodymus.    The  same  as  the  preceding,  except  that  the 

union  is  higher,  including  the  lower  part  of  the  thorax. 

c.  Derodymus.     A  single  body  with  two  necks  and  two  heads. 

As  a  rule,  there  are  two  upper  and  two  lower  extremities, 
although  additional  rudimentary  limbs  may  be  present. 

6.  MoNOSOMic  Monsters. — These  monsters  have  practically  a 
single  body  with  two  heads. 

a.  Atlodymus.     Two  heads  and  a  single  body.     The  organiza- 

tion of  the  body  is  strictly  single. 

b.  Miodymus.     This  monster  differs  from  the  preceding  in  that 

the  two  heads  are  united  posteriorly,  the  union  between 


164  ESSENTIALS    OF    OBSTETEICS. 

the  necks  not  being  complete  in  all  cases.  The  number 
of  ears  varies, 
c.  Opodymus.  The  union  between  the  heads  is  more  exagge- 
rated than  in  the  preceding  variety.  The  faces  are  closer 
together,  and  the  mouths  are  either  separate,  or  have  a 
common  opening.  In  either  case  the  mouth  posteriorly 
is  always  united.  The  tongue  is  always  joined  poste- 
riorly, even  when  it  is  double  anteriorly.  The  number  of 
eyes  varies. 

Name  and  describe  the  parasite  monsters. 

1.  Heteropagus.  —  There  are  upper  and  lower  extremities  and 
one  head.  The  parasite  is  attached  to  the  anterior  abdominal 
wall  of  the  principal  foetus. 

2.  Heteradelphus.  —  The  head  of  the  parasite  is  absent,  and  the 
body,  with  or  without  the  upper  extremities,  is  attached  to  the 
principal  foetus  at  the  level  of  the  epigastrium. 

3.  Epicome. — Where  there  is  an  accessory  head  united  by  the 
summit  to  the  head  of  the  principal  foetus. 

4.  Epignathus.  — Where  the  parasite  is  attached  to  the  superior 
maxillary  bone. 

5.  HypognathuB. — Where  the  parasite  is  attached  to  the  inferior 
maxillary  bone. 

6.  Pygomelus.  —  Where  the  parasite  is  inserted  into  the  hypo- 
gastric region. 

Dystocia  in  Plural  Deliveries. 

What  are  the  predisposing^  causes  of  dystocia  in  plural 
births  ? 

The  large  size  of  the  pelvis,  or  the  small  size  of  the  foetuses,  or 
their  being  contained  in  a  single  sac. 

What  are  the  determining  causes  ? 

The  injudicious  use  of  ergot,  or  interference  with  the  progress 
of  labor,  as  by  premature  rupture  of  the  membranes. 

In  what  ways  may  delivery  be  arrested  in  twin  births  ? 

1.  Both  heads  may  present  at  the  superior  strait  (rare). 

2.  Both  heads  may  present  and  one  descend  into  the  pelvis 


LABOK.  165 

somewhat  in  advance  of  the  other,  the  last  head  being  forced 
against  the  neck  of  the  first  child. 

3.  The  body  of  the  first  presents  by  the  breech  and  is  delivered, 
and  then  the  head  of  the  second  child  entering  the  pelvis  becomes 
interlocked  with  the  head  of  the  first.  The  interlocking  may  be 
chin  to  chin,  occiput  to  occiput,  or  chin  to  occiput. 

4.  The  first  child  descends  by  the  head,  and  the  second  by  the 
breech,  the  bag  of  waters  of  the  latter  protruding  in  advance  of 
the  former  obstructs  its  descent. 

5.  The  foetuses  may  present  by  the  breech,  and  the  feet  of  both 
descend  at  the  same  time  into  the  pelvic  cavity. 

6.  The  first  foetus  descends  by  the  head,  and  the  second  is  trans- 
verse. The  head  of  the  former,  after  descending  into  the  pelvic 
cavity,  may  be  arrested  by  the  neck  of  the  latter  getting  under 
the  shoulder  and  locking  against  the  neck. 

7.  The  first  foetus  descends  by  the  breech,  and  the  second  is 
transverse.  After  delivery  of  the  body  of  the  former,  the  head 
may  be  arrested  by  the  trunk  of  the  latter. 

8.  The  first  child  may  be  transverse,  and  the  second  present  by 
the  breech.  The  limbs  of  the  second  child  passing  over  on  each 
side  of  the  body  of  the  first,  descend  into  the  vagina — i.  e.,  the 
former  twin  is  sitting  astride  the  latter. 

How  is  the  arrest  of  labor,  occurring  in  the  delivery  of 
twins,  managed  ? 

The  life  of  the  mother  is  the  first  consideration,  and  next  the 
safety  of  the  foetuses.  If  both  twins  cannot  be  delivered  alive, 
our  efibrts  should  be  directed  toward  saving  one  of  them. 

If  the  bag  of  waters  of  the  second  child  is  in  advance  of  the 
head  of  the  first,  obstructing  its  descent,  rupturing  the  membranes 
will  relieve  the  difficulty. 

In  all  cases  where  interlocking  of  the  foetuses  is  the  cause  of  the 
arrest  of  delivery,  the  first  indication  is  to  endeavor,  by  external 
and  internal  manipulations,  to  decompose  theavedge  by  unlocking 
them.  Failing  in  this,  delivery  may  be  effected  with  the  forceps; 
but  if  this  is  unsuccessful,  embryotomy  must  be  resorted  to. 

Where  the  first  child  presents  by  the  breech,  and  the  second  by 
the  vertex,  if  labor  is  arrested  after  the  delivery  of  the  trunk  of 


166  ESSENTIALS    OF    OBSTETRICS. 

the  former,  by  the  interlocking  of  the  two  heads,  the  woman 
should  be  placed  in  the  knee-chest  position,  the  body  of  the  first 
child  supported  with  one  hand,  while  the  other  introduced  into 
the  vagina  pushes  up  the  head  of  the  second.  If  unlocking  is 
impossible,  then  apply  the  forceps  to  the  head  of  the  second  child, 
and  endeavor  to  deliver.  As  a  rule,  however,  unless  the  pelvis  is 
large,  and  the  foetuses  small,  one  of  the  twins  will  have  to  be  sacri- 
ficed before  the  wedge  is  decomposed.  This  must  be  accomplished 
by  detaching  the  head  of  the  first  child,  or  by  performing  crani- 
otomy. 

Where  both  heads  present  simultaneously  at  the  inlet,  introduce 
the  hand  into  the  vagina  and  push  one  of  the  heads  out  of  the 
way,  at  the  same  time  assisting  the  manipulation  with  the  other 
hand  externally.  Then  apply  the  forceps  to  the  other  head,  so  as 
to  cause  it  at  once  to  engage. 

If  both  foetuses  present  by  the  vertex,  one  somewhat  in  advance 
of  the  other,  so  that  delivery  of  the  first  child  is  prevented  by  the 
pressure  of  the  head  of  the  second,  against  its  neck  or  thorax,  an 
endeavor  should  be  made  to  push  up  the  second  head.  Failing 
in  this,  apply  the  forceps  to  the  first  head.  If  delivery  cannot  be 
accomplished  by  the  forceps,  craniotomy  must  be  resorted  to ;  the 
child  in  advance  being  the  one  sacrificed. 

Prolapse  of  the  Funis. 

What  is  the  frequency  of  prolapse  of  the  cord  ? 

Authorities  difier.     Probably  it  occurs  once  in  about  225  labors. 

What  are  the  causes  of  the  prolapse  ? 

Prolapse  of  the  cord  only  occurs  when  the  presenting  part  fails 
to  occupy  completely  the  lower  segment  of  the  uterus ;  hence  the 
accident  is  more  frequent  in  presentations  of  the  face,  shoulder,  or 
pelvis,  than  when  the  vertex  presents.  Again,  the  small  size  of 
the  foetus,  the  oblique  position  of  the  uterus,  deformities  of  the 
pelvis,  especially  when  it  is  contracted,  and  multiple  pregnancies 
are  predisposing  causes.  Among  other  causes  may  be  mentioned 
hydramnios,  premature  rupture  of  the  membranes,  great  length  of 
the  cord,  or  marginal  attachment,  placenta  prsevia,  and  prolapse 
of  the  foetal  extremities. 


LABOR.  167 

What  is  the  diagnosis  of  prolapse  of  the  cord  ? 

Before  Rupture  of  the  Membranes. — The  examinations  should  be 
made  in  the  interval  of  uterine  contractions.  The  examining 
finger  feels  a  round,  smooth,  compressible  object,  which  can  be 
moved  about  in  different  directions.  It  presents  to  the  touch 
none  of  the  characteristics  of  a  hand  or  foot,  therefore  the  diag- 
nosis is,  as  a  rule,  devoid  of  difficulty.  If  the  foetus  be  alive,  pul- 
sations may  be  felt  through  the  membranes. 

After  Rupture. — The  diagnosis  is  without  difficulty,  there  being 
nothing  that  the  cord  can  be  mistaken  for. 

What  is  the  prognosis  ? 

There  is  no  danger  to  the  mother,  but  the  results  of  the  accident 
are  very  grave  to  the  child.  The  danger  to  the  child  depends 
upon  the  presentation.  Thus,  in  a  shoulder  presentation,  there  is 
little  or  no  danger,  and  in  a  breech  the  prognosis  is  good ;  Char- 
pentier,  however,  holds  that  the  accident  is  grave  to  the  child  in 
a  presentation  of  the  pelvis.  The  most  dangerous  cases  are  those 
where  the  accident  occurs  in  a  head  presentation.  The  favorable 
conditions  in  prolapse  of  the  cord  are,  a  large  pelvis,  the  funis 
occupying  the  sides  of  the  pelvis,  and  the  preservation  of  the  bag 
of  waters  until  dilatation  of  the  cervix  is  completely  effected.  As 
unfavorable  conditions  may  be  mentioned,  a  contracted  pelvis, 
placenta  praevia,  and  premature  rupture  of  the  bag  of  waters. 

What  is  the  treatment  ? 

The  cause  of  death  of  the  foetus  is  asphyxia  from  pressure  upon 
the  cord.  Recognizing  the  cause  of  death  the  indication  in  the 
treatment  is  obvious. 

Head  Presentations. — Before  Rupture.  The  patient  should  be 
placed  in  the  latero-prone  position,  upon  the  side  opposite  to  the 
prolapse.  All  bearing-down  efforts  are  forbidden,  and  the  prema- 
ture rupture  of  the  membranes  guarded  against.  The  membranes 
may  be  supported  by  introducing  a  Barnes's  dilator  into  the  vagina 
and  moderately  distending  it.  If,  upon  auscultation,  there  are 
signs  of  failure  in  the  foetal  circulation,  endeavor  to  push  up  the 
cord  through  the  membranes.     If  this  can  be  done,  rupture  the 


168  ESSENTIALS    OF    OBSTETRICS. 

membranes,  and  bring  the  head  well  down  so  as  to  fill  the  lower 
uterine  segment. 

After  Rupture.  If  the  cervix  is  completely  dilated,  the  uterine 
contractions  strong,  and  the  head  rapidly  descends,  leave  the  case 
to  nature.  If,  however,  the  progress  of  labor  is  slow,  apply  the 
forceps.  When  the  head  is  above  the  inlet  and  movable,  the 
forceps  are  contra-indicated.  Delivery  in  such  cases  must  be 
accomplished  by  version,  or  reposition  of  the  cord  effected ;  the 
latter  procedure  should  be  tried  first.  In  all  cases  of  prolapse  of 
the  cord  the  condition  of  the  child  must  be  from  time  to  time 
determined  by  auscultation.  When  the  case  is  left  to  nature,  the 
cord  should  be  placed  near  one  or  the  other  of  the  sacro-iliac 
joints,  where  it  will  be  least  pressed  upon. 

Face  Presentations. — Podalic  version  is  indicated,  as  reposition 
of  the  cord  is  not  likely  to  succeed. 

Presentations  of  the  Feet. — The  cord  is  not  pressed  upon  before 
the  feet  can  be  reached  and  traction  made. 

Breech  Presentations.  —  If  the  circulation  in  the  cord  is  inter- 
fered with,  bring  down  a  leg. 

Shoulder  Presentations. — There  is  no  special  indication  for  treat- 
ment, except  that  of  the  abnormal  presentations. 

If  the  pulsations  in  the  cord  have  ceased,  it  must  not  be  taken 
for  granted  that  the  child  is  dead,  as  the  heart  may  continue  its 
action  for  several  minutes  after  the  circulation  in  the  umbilical 
vessels  has  ended.  If  the  child  be  dead,  the  delivery  should  be 
managed  without  reference  to  the  prolapsed  condition  of  the  cord. 

By  what  methods  may  reposition  of  the  cord  be  effected  ? 

By  the  manual,  instrumental,  or  postural  treatment. 

Describe  these  methods. 

Manual  Treatment. — Push  the  cord  beyond  the  presenting  part 
with  the  fingers,  and  keep  it  in  that  position  until  a  uterine  con- 
traction comes  on,  and  then  gently  withdraw  the  hand  from  the 
vagina;  or,  after  it  is  replaced  place  a  sponge  between  the  pre- 
senting part  and  the  uterine  wall.  In  some  cases  the  cord  may 
be  placed  around  one  of  the  foetal  extremities. 

Instrumental  Treatment. — Take  a  piece  of  tape,  double  it  and 
pass  it  through  a  firm  rubber  catheter,  so  that  the  loop  emerges  at 


LABOR.  169 

the  eye  of  the  instrument.  Next  pass  a  loop  of  the  prolapsed  cord 
through  the  end  of  the  tape.  Now  draw  upon  the  free  ends  of  the 
tape  with  sufficient  force  to  keep  the  cord  from  slipping,  care  being 
taken  not  to  cut  off  the  circulation.  After  the  free  ends  of  the 
tape  have  been  tied  into  a  knot,  introduce  the  stylet  and  carry  the 
catheter  and  cord  up  into  the  uterine  cavity.  The  stylet  is  now 
withdrawn,  the  catheter  being  allowed  to  remain  until  the  head 
has  descended. 

Postural  Treatment. — Place  the  patient  in  the  knee-chest  position, 
and  in  the  interval  of  a  pain  introduce  the  hand  into  the  vagina, 
seize  the  cord  and  carry  it  beyond  the  presenting  part,  and  at  the 
same  time  support  the  uterus  with  the  other  hand  placed  exter- 
nally. As  the  head  descends  and  occupies  the  lower  segment  of 
the  uterus,  the  hand  should  be  gradually  withdrawn.  The  patient 
is  then  placed  upon  her  side  with  the  buttocks  elevated. 

Deformities  of  the  Pelvis. 

How  are  deformities  of  the  pelvis  divided? 

Into  1.  Deformities  of  position. 

2.  Deformities  of  size. 

3.  Deformities  of  forms. 

What  are  the  deformities  of  position  ? 

The  normal  obliquity  of  the  pelvis  is  either  increased  or  dimin- 
ished. If  it  be  increased,  the  plane  of  the  inlet  becomes  more  or 
less  vertical,  while  the  axis  assumes  a  horizontal  position.  If,  on 
the  other  hand,  the  obliquity  be  decidedly  diminished,  the  plane 
of  the  superior  strait  becomes  horizontal. 

What  are  the  deformities  of  size  ? 

These  pelves  are  either  increased  or  lessened  in  size  ;  the  change 
being  symmetrical. 

1.  The  pelvis  cequabiliter  Justo-major,  or  the  symmetrically 
enlarged  pelvis. 

2.  The  pelvis  cequabiliter  justo-minor,  or  the  symmetrically  con- 
tracted pelvis. 

a.  The  infantile  pelvis.  This  pelvis  has  the  characteristics  of 
the  sex,  but  there  has  been  an  arrest  in  development. 
This  is  a  rare  form. 


170       ESSENTIALS  OF  OBSTETRICS. 

b.  The  dwarfs  'pelvis.     This  variety  is  very  rare.     It  has  the 

characteristics  of  the  female  pelvis,  but  is  smaller. 

c.  The  masculine  pelvis.     This  has  the  characteristics  of  the 

male  pelvis. 

What  are  the  deformities  of  form  ? 

1.  Those  pelves  in  which  the  vertical  measurements  are  increased, 
without  any  change  in  the  horizontal. 

2.  Those  pelves  in  which  the  vertical  measurements  are  dimin- 
ished. These  pelves,  as  a  rule,  are  asymmetrically  deformed,  and 
are  divided  into  three  classes,  viz. : 

a.  Those  principally  contracted  in  the  antero-posterior  diam- 
eter. 
h.  Those  principally  contracted  in  the  transverse  diameter, 
c.  Those  principally  contracted  in  the  oblique  diameter. 

Name  the  pelves  principally   contracted  in  the  antero- 
posterior diameter. 

1.  The  simple  flat  pelvis. 

2.  The  rachitic  flat  pelvis. 

3.  The  generally  contracted  flat  pelvis. 

4.  The  spondylisthetic  pelvis. 

5.  The  pelvis  flattened  by  double  laxation. 

6.  The  lumbo-lordotic  pelvis. 

Name  the  pelves  principally  contracted  in  the  transverse 
diameter. 

1.  The  osteomalacic  pelvis. 

2.  The  ankylotic  transversely  contracted  pelvis. 

3.  The  kyphotic  transversely  contracted  pelvis. 

Name   the   pelves   principally  contracted  in  the  oblique 
diameter. 

1.  The  ankylotic  obliquely  contracted  pelvis. 

2.  Coxalgic  pelvis. 

3.  The  scoliotic  pelvis. 

In  what  way  may  an  increased  obliquity  of  the  pelvis 
interfere  with  labor  ? 

The  advance  of  the  head  may  be  retarded  by  pressing  against 
the  superior  surface  of  the  symphysis  pubis. 


LABOR.  171 

How  is  the  difficulty  overcome  ? 

By  placing  the  patient  in  a  half-sitting  position,  by  elevating 
the  hips  and  the  upper  part  of  the  body,  or  if  she  is  upon  the 
side,  have  her  bend  the  back  forward  and  flex  her  thighs  upon  the 
pelvis. 

How  is  the  difficulty  overcome  if  lessened  obliquity  of  the 
pelvis  interferes  with  labor? 
By  raising  the  lumbar  region  and  placing  the  coccyx  lower. 

What  are  the  mechanism  and  treatment  of  labor  in  the 
justo-minor  pelvis? 

The  head  does  not  descend  into  the  pelvic  cavity  in  the  latter 
part  of  pregnancy,  but  is  at  the  superior  strait  when  labor  begins. 
The  head  descends  strongly  flexed,  the  biparietal  diameter 
being  in  relation  with  the  conjugate,  and  the  suboccipito-breg- 
matic  with  the  transverse.  The  head  does  not  undergo  anterior 
rotation,  but  delivery  occurs  by  the  occiput  passing  out  over  the 
perineum.  The  caput  succedaneum  is  larger  than  in  normal 
labor. 

If  the  antero  posterior  diameter  of  the  inlet  measures  3.5  inches, 
induce  labor  at  eight  months;  if  3.1  inches,  the  indication  is 
positive.  If  below  3.1  inches,  the  choice  lies  between  the  Csesarean 
section  and  embryotomy.  If  below  2  inches,  perform  the  Csesarean 
section.  Some  authorities  consider  the  indication  absolute  when 
the  conjugate  measures  2.5  inches,  or  less. 

The  forceps  should  not  be  applied  until  the  head  is  moulded. 
If  the  head  presents,  prodalic  version  is  contra-indicated. 

If  the  contraction,  is  principally  in  the  superior  strait,  the 
mechanism  of  labor  and  its  treatment,  after  the  head  has  entered 
the  pelvic  cavity,  correspond  with  a  normal  labor. 

What  are  the  mechanism  and  treatment  of  labor  in  the 
simple  flat  and  in  the  rachitic  flat  pelvis  ? 

The  head  does  not  enter  the  pelvic  cavity  in  the  latter  part  of 
pregnancy  as  is  usual  in  primigravidse,  but  in  some  cases  it  may 
turn  aside  at  the  superior  strait,  thus  increasing  the  proportion  of 
shoulder  presentations.  If  the  head  presents  when  labor  occurs, 
the  sagittal  suture  lies  in  the  transverse  diameter.     The  head  is 


172  ESSENTIALS    OF    OBSTETRICS. 

partially  deflected,  and  the  fontanelles  (anterior  and  posterior)  are 
on  the  same  level.  The  transverse  diameter  is  in  relation  with  the 
conjugate,  and  the  occipito-frontal  with  the  transverse.  The 
sagittal  suture  is  directed  toward  the  promontory.  The  anterior 
parietal  bone  now  becomes  the  fixed  point  and  pivots  against  the 
pubes,  while  the  posterior  parietal  descends  below  the  promontory. 
In  order  to  accomplish  this  descent,  the  transverse  diameter  of 
the  foetal  head  must  be  shortened.  In  some  cases  the  posterior 
parietal  bone  may  become  fixed  against  the  promontory,  and  the 
anterior  parietal  descend  first.  After  the  head  has  descended  into 
the  cavity,  delivery  is  effected  by  the  normal  mechanism  of  labor. 
In  a  pelvis  where  there  is  a  marked  projection  of  the  promontory, 
giving  to  the  superior  strait  the  form  of  the  figure  8,  the  head 
may  descend  through  one  side  of  the  inlet;  of  course,  this  can 
only  occur  when  the  head  is  very  small  and  the  pelvis  originally 
very  wide,  the  mechanism  being  the  same  as  in  the  generally 
contracted  pelvis. 

In  breech  presentations,  the  feet,  as  a  rule,  descend  first ;  if  the 
deformity  be  slight,  the  delivery  of  the  body  is  followed  by  that 
of  the  head  in  a  transverse  position  and  flexed. 

In  the  treatment  of  labor  care  should  be  taken  to  prevent  pre- 
mature rupture  of  the  membranes.  If  the  head  fails  to  pass  the 
inlet,  the  indication  is  to  deliver  by  the  forceps  or  version.  The 
same  rules  guide  us  in  the  indications  for  the  Caesarean  section,  or 
embryotomy,  as  already  referred  to,  under  the  head  of  the  generally 
contracted  pelvis. 

How  is  the  diagnosis  of  pelvic  deformities  made  ? 

1.  Probable  Signs. — 
a.  History  of  patient.  Inquire  as  to  the  diseases  of  infancy 
and  childhood ;  the  age  when  walking  began ;  as  to  any 
congenital  or  acquired  deformities ;  as  to  injuries  of  the 
spine  or  pelvis,  and  whether  a  luxation  of  one  of  the 
femurs  occurred  in  early  life.  If  the  woman  has  previ- 
ously been  pregnant,  inquire  as  to  her  labors,  whether 
natural  or  artificial;  also  as  to  whether  the  child  was  de- 
livered living  or  was  still-born. 


LABOR.  173 

b.  Appearance  of  the  body  of  the  patient.    See  if  the  hips  are  on 
the  same  level,  or  if  any  ankylosis  of  the  joints  exists. 
Examine  the  spine,  and  if  any  abnormal  curvature  exists 
inquire  when  it  made  its  appearance.     If  the  deformity 
occurred  in  infancy,  the  disease  was  probably  rickets  and 
the  lower  limbs  will  generally  be  found  bent,  and,  as  a 
rule,  a  deformity  of  the  pelvis  exists.   On  the  other  hand, 
if  the  deformity  first  manifested  itself  in  late  childhood, 
it  was  not  caused  by  rickets,  and  the  pelvis  is  probably 
normal.     If  the  patient  is  lame,  inquire  as  to  the  cause 
and  the  age  when  the  deformity  first  occurred. 
2.  Certain  Signs. — These  signs  are  determined  by  pelvic  measure- 
ments or  pelvimetry.     The  instrument  with  which  these  measure- 
ments are  made  is  called  the  pelvimeter.     Before  using  the  pelvi- 
meter,  the   accoucheur  should  determine,  with   his   hands,  the 
position  of  the  hips,  the  size  of  the  iliac  bones,  the  depth  of  the 
iliac  fossae,  the  width  and  curve  of  the  sacrum,  and  the  position  of 
the  pubic  symphysis. 

1.  External  Pelvimetry. — 

a.  Between  the  anterior  superior  processes  of  the  iliac  bones, 

10  inches. 

b.  The  greatest  distance  between  the  iliac  crests,  11  inches. 

c.  The  distance  between  the  great  trochanters,  12^  inches. 

If  these  measurements  are  normal,  there  is  no  lessening 
in  the  transverse  diameters  of  the  pelvis. 

d.  The  external  conjugate,  7.9  inches.   This  diameter  is  deter- 

mined by  placing  one  of  the  knobs  of  the  pelvimeter  over 
the  spinous  process  of  the  last  lumbar  vertebra,  and  the 
other  upon  the  middle  of  the  anterior  surface  of  the  pubic 
symphysis.  By  deducting  3.1  inches  from  the  measure- 
ment of  the  external  conjugate,  we  approximately  deter- 
mine the  true  conjugate.  If  the  external  conjugate  is 
decidedly  lessened,  we  know  that  the  true  conjugate  is 
decreased. 

e.  The  circumference  of  the  false  pelvis  is  35.5  inches.     To 

determine  this  measurement  we  place  the  end  of  a  tape- 
measure  at  the  spinous  process  of  the  last  lumbar  verte- 
bra, and  carry  the  tape  along  the  crest  of  the  iliac  bone 


174 


ESSENTIALS    OF    OBSTETRICS. 


to  the  middle  of  the  pubic  symphysis ;  in  the  same  way 
the  other  side  of  the  pelvis  is  measured.  By  adding 
together  the  results  of  these  measurements  the  circum- 
ference of  the  entire  pelvis  is  determined.    If  one  side  of 


Fig.  7. 


Measuring  the  diagonal  conjugate. 

the  pelvis  measures  more  than  the  other,  it  is  asymmetri- 
cal. We  may  also  ascertain  any  want  of  symmetry  of  the 
pelvis  by  "  measuring  the  distance  of  the  trochanter  of 
one  side,  to  the  middle  of  the  iliac  crest  of  the  other,"  and 
vice  versa. 
2.  Internal  Pelvimetry. — 
a.  The  diagonal  conjugate.  This  diameter  is  taken  from  the 
posterior  edge  of  the  symphysis  pubis  to  the  sacro-verte- 
bral  angle.  The  index  and  middle  fingers  of  the  left 
hand  are  introduced  into  the  vagina  and  carried  upward 
and  backward  until  they  touch  the  sacro-vertebral  angle. 
Then  the  nail  of  the  index  finger  of  the  other  hand  marks 
the  point  of  contact  of  the  internal  hand  with  the  sub- 
pubic ligament;  the  fingers  are  now  withdrawn  from  the 
vagina,  and  the  distance  from  this  mark  to  the  tip  of  the 
finger  measured.  To  determine  the  true  conjugate  we 
subtract  from  this  measurement  five-tenths  to  seven-tenths 
of  an  inch,  if  the  height  of  the  symphysis  is  one  inch  and 


LABOB,  175 

a  half.  This  subtraction  will,  of  course,  vary  somewhat 
in  the  different  deformities  of  the  pelvis. 
Measurements  of  the  Outlet.— These  diameters  are  of  less 
importance  than  those  just  described.  To  determine  the 
antero-posterior  diameter,  place  the  patient  upon  her  side 
(left),  and  with  the  index  finger  of  the  right  hand  intro- 
duced into  the  vagina,  while  the  thumb  is  placed  ex- 
ternally, include  between  them  the  sacro-coccygeal  joint. 
The  tip  of  the  finger  is  kept  pressed  against  the  joint 
while  the  point  of  contact  with  the  subpubic  ligament  is 
marked  by  the  nail  of  the  index  finger  of  the  left  hand. 
The  finger  is  then  withdrawn  and  the  distance  measured. 
The  antero-posterior  diameter  may  also  be  measured  by 
the  pelvimeter.  One  knob  is  placed  externally  over  the 
sacro-coccygeal  joint,  while  the  other  is  pressed  against 
the  under  surface  of  the  symphysis  pubis.  The  actual 
diameter  is  then  obtained  by  subtracting  from  this 
measurement  1  to  1.5  centimeters. 

The  transverse  diameter  is  obtained  by  placing  the 
knobs  of  the  pelvimeter  upon  the  tuberosities  of  the 
ischise  and  deducting  from  the  distance  measured  between 
these  two  points,  1-2  centimeters. 

What  is  the  diagnosis  of  the  generally  contracted  pelvis? 

All  of  the  measurements  are  found  to  be  below  normal.  In  the 
masculine  pelvis,  however,  owing  to  the  thickness  of  the  bones, 
the  distances  between  the  iliac  crests  and  between  the  anterior 
superior  spinous  processes  of  the  iliac  bones  are  found  to  be  but 
slightly  altered,  or  even  normal. 

What  is  the  diagnosis  of  the  simple  flat  pelvis  ? 

The  transverse  diameters  and  the  circumference  of  the  false 
pelvis  are  normal ;  the  former  may  be  slightly  increased,  and  the 
latter  slightly  decreased,  but  symmetrical.  The  external  conju- 
gate is  always  lessened,  the  true  conjugate,  in  most  cases,  being 
3.1  inches. 

What  is  the  diagnosis  of  the  simply  flat  rachitic  pelvis  ? 
There  is  a  history  of  rickets  and  evidences  of  the  disease  in  other 


176  ESSENTIALS    OF    OBSTETRICS. 

portions  of  the  skeleton.  The  distances  between  the  anterior 
superior  spinous  processes  and  between  the  iliac  crest  are  equal ; 
the  distance  in  some  cases  between  the  former  exceeds  that  be- 
tween the  latter.  The  external  conjugate  is  always  shortened; 
the  true  conjugate  is  diminished.  The  anterior  posterior,  as  well 
as  the  transverse  diameters  of  the  pelvic  outlet,  are  large,  compared 
with  the  deformity  at  the  superior  strait. 

Rupture  of  the  Uterus. 

"What  are  the  causes  of  rupture  of  the  uterus  ? 

The  chief  cause  is  thinning  of  the  lower  uterine  segment.  Other 
causes  are  direct  violence,  attrition,  and  the  rupture  of  a  one- 
horned  uterus. 

What  are  the  conditions  necessary  for  a  rupture  to  occur  ? 

Malpresentation  or  undue  size  of  the  foetus  (hydrocephalus),  or 
pelvic  deformity. 

Explain  the  mechanism  of  rupture  due  to  thinning  of  the 
lower  segment. 

In  a  normal  labor  the  upper  segment  (fundus  and  body)  of  the 
uterus  thickens,  while  the  lower  is  thinned  and  stretched.  The 
boundary  line  between  these  two  portions  of  the  uterus  is  marked 
by  a  ridge,  which,  however,  is  not  the  internal  os  uteri,  but  is  due 
to  a  retraction  of  the  muscular  fibres  of  the  body  and  fundus. 
This  ridge  is  termed  the  "contraction  ring,"  or  ring  of  Bandl,  or 
Schroeder.  This  ridge  or  contraction  ring,  during  a  normal  labor, 
is  situated  on  a  level  with  the  pelvic  inlet.  Now  suppose,  instead 
of  the  normal  resistance  to  the  advancing  presentation,  one  or 
other  of  the  conditions  necessary  for  rupture  to  occur  exists ;  we 
will  then  have  the  uterine  elForts  increased,  and  the  contrac- 
tion ring  will  be  withdrawn  upward  until  it  reaches  above  the 
pubes,  or  in  the  neighborhood  of  the  umbilicus.  Thus,  the  lower 
segment  of  the  uterus  will  be  greatly  thinned  and  stretched,  while 
the  fundus  will  be  thickened. 

What  is  the  diagnosis  of  threatened  rupture  ? 

1.  The  contraction  ring  is  high  up,  at  or  near  the  umbilicus. 


LABOK. 


177 


It  is  higher  on  the  left  than  on  the  right  side,  on  account  of  the 
right  obliquity  of  the  uterus. 

2.  Above  the  contraction  ring  the  uterus  is  thickened ;  below, 
stretched  and  thinned. 

3.  The  round  ligaments  are  greatly  thickened,  and  feel  like 
tense  cords. 

4.  There  is  great  pain  in  the  supra-pubic  region. 

5.  The  labor  is  protracted,  and  the  presenting  part  fails  to 
descend.  • 

Fig.  8. 


Thinning  of  the  lower  uterine  segment. 


What  is  the  diagnosis  of  rupture  ? 

If  the  rupture  occurs  suddenly,  uterine  contractions  cease  and 
symptoms  of  collapse  set  in ;  signs  of  internal  hemorrhage  and 
shock  intervene,  and  blood  escapes  from  the  vagina.  There  is 
also  a  recession  of  the  presenting  part.  If  the  child  escapes  into 
the  abdominal  cavity,  the  uterus  will  be  found  to  be  empty,  and 
the  foetal  outlines  can  be  traced  by  palpation. 

12 


178  ESSENTIALS    OF    OBSTETRICS. 

If  the  rupture  be  incomplete,  the  symptoms  are  less  pronounced. 
The  presenting  part  does  not  recede,  and  uterine  contractions 
may  continue. 

What  are  the  causes  of  death  following  rupture  ? 

Septicaemia,  shock,  and  hemorrhage. 

What  is  the  prophylactic  treatment  ? 

The  accoucheur  should  guard  against  this  accident  by  the  recog- 
nition and  removal  of  the  cause.  The  treatment  of  undue  size 
(hydrocephalus)  and  mal presentations  of  the  foetus  and  pelvic 
deformities  has  been  discussed  elsewhere.  If  the  foetus  be  dead 
and  the  shoulder  presents,  embryotomy  is  indicated  if  symptoms 
of  threatened  rupture  are  present. 

What  are  the  indications  in  the  treatment  of  rupture  ? 

1.  Escape  of  child  entirely  or  chiefly  into  the  abdominal  cavity 
The  indication  is  abdominal  section. 

2.  Child  partly  within  and  partly  without  the  uterus.  The 
indications  are : 

a.  Deliver  by  the  natural  passages  if  it  can  be  accomplished 

without  enlarging  the  uterine  opening  ;  or, 
h.  If  this  cannot  be  done,  then  perform  abdominal  section. 

3.  If  the  child  is  entirely  within  the  uterus,  deliver  by  the 
natural  passages. 

Abdominal  section  is  probably  indicated  in  all  cases  of  complete 
rupture,  even  where  extraction  per  vias  naturales-  has  been  accom- 
plished, unless  uterine  retractions  close  the  laceration. 

Inversion  of  the  Uterus. 

What  is  inversion  of  the  uterus  ? 

The  fundus  becomes  more  or  less  depressed,  so  that  the  serous 
covering  is  internal  while  the  mucous  coat  is  external ;  ''  the  organ 
is  up-side  down  and  wrong-side  out. " 

How  many  degrees  of  inversion  are  recognized  ? 

Three,  viz.,  1,  simple  depression  of  the  fundus;  2,  partial  inver- 
sion, i.  e.,  where  the  fundus  descends  and  is  surrounded  by  the 


LABOR.  179 

cervix ;  3,  complete  inversion,  or  where  the  uterus  protrudes  out- 
side of  the  vulva. 

What  are  the  causes  ? 

Inversion  of  the  uterus  is  always  preceded  by  paresis  of  a  portion 
of  the  uterine  muscles,  some  authorities  holding  that  the  paralysis 
is  at  the  placental  site.  Among  the  immediate  causes  are,  pressure 
upon  the  fundus  over  the  abdomen,  and  traction  upon  the  cord, 
the  result  either  of  a  short  cord  or  delivery  in  the  erect  position, 
or  to  interference  on  the  part  of  the  accoucheur.  Violent  bearing- 
down  efforts  will  also  cause  the  accident  under  favorable  conditions. 

What  are  the  symptoms  of  acute  inversion  ? 

1,  pain ;  2,  shock ;  3,  hemorrhage. 

The  more  sudden  the  inversion  the  greater  the  pain.  The  hemor- 
rhage may  or  may  not  be  profuse. 

What  is  the  diagnosis  ? 

There  will  be  found  in  the  vagina,  or  projecting  from  the  vulva^ 
a  large,  soft,  globular  tumor,  livid  red  in  color,  which  is  limited 
above  by  a  constriction,  the  cervix  uteri.  The  placenta  may  or 
may  not  be  adherent  to  the  tumor.  Palpating  over  the  hypogas- 
trium  the  absence  of  the  uterus  will  be  noted. 

An  inverted  uterus  may  be  mistaken  for  a  fibrous  polypus,  but 
this  error  can  be  guarded  against  by  a  careful  manual  examination. 
The  bladder  should  in  all  cases  be  emptied  with  a  catheter. 

What  is  the  prognosis  ? 

The  prognosis  depends  upon  the  rapidity  with  which  the  uterus 
is  restored.  The  greater  the  delay  the  more  difficult  the  reduction 
becomes,  and  the  more  serious  the  condition  of  the  patient.  The 
causes  of  death  are,  shock,  hemorrhage,  and  inflammation,  or 
gangrene  of  the  uterus. 

What  is  the  treatment  ? 

If  the  placenta  is  adherent,  remove  it,  and  at  once  reduce  the 
uterus  to  its  normal  position.  The  following  methods  are  advised 
to  effect  reduction : 

1.  Central  Taxis. — Pressure  is  made  against  the  fundus  of  the 
uterus  with  the  fingers  in  the  form  of  a  cone,  or  with  the  fist. 


180  ESSENTIALS    OF    OBSTETRICS. 

2.  Peripheral  Taxis. — Rest  the  fundus  in  the  palm  of  the  hand, 
and  place  the  fingers  and  thumb  along  the  sides  of  the  body  of  the 
uterus,  and  insert  them  into  the  constriction  at  the  cervix.  Then, 
gradually  stretch  the  cervical  ring,  at  the  same  time  endeavoring 
to  glide  the  body  of  the  uterus  past  the  constriction.  By  this 
method  we  return  first  that  part  of  the  uterus  which  escaped  last. 

3.  Lateral  Taxis. — The  uterus  is  grasped  by  the  hands,  the  fingers 
making  counter-pressure,  while  the  thumb  depresses  the  opposite 
side  at  the  point  of  constriction.  The  thumb,  by  increasing  the 
depression,  sinks  further  and  further,  until  the  entire  mass  is 
reduced. 

4.  NoeggeraWs  Method. — This  "consists  in  placing  the  index 
finger  on  one  cornu  of  the  uterus,  and  the  thumb  on  the^  other, 
and  in  endeavors  made  to  push  in  first  one  and  then  the  other." 

In  performing  taxis  counter-pressure  must  be  made  with  the 
disengaged  hand,  either  above  the  pubes,  or  by  two  fingers  intro- 
duced into  the  rectum.  In  all  cases  of  recent  inversion  the  rule  is 
to  use  the  hands,  and  not  instruments,  in  efiecting  reduction. 
After  reduction  has  been  accomplished,  the  subsequent  treatment 
is  that  of  uterine  atony. 

Post-partum  Hemorrhage. 

How  is  post-partum  hemorrhagic  divided  ? 

Into  1.  Primary  hemorrhage,  within  six  hours  after  delivery. 
2.  Secondary  hemorrhage,  subsequent  to  the  first  six  hours,  and 
before  the  end  of  one  month. 

Primary  Hemorrhage. 

What  are  the  causes  of  primary  post-partum  hemorrhage? 
Uterine  inertia  is  the  prime  cause.     Inertia  may  depend  upon 

great  distention  of  the  uterus  (polyhydramnios,  twins,  etc.),  a  rapid 
or  slow  labor,  a  feeble  constitution,  albuminuria,  anaemia,  emotional 
causes,  a  predisposition  to  hemorrhage  in  certain  women,  and  im- 
perfect development  of  the  muscular  fibres  of  the  uterus. 

Neoplasms  of  the  uterus,  tears,  and  inversion,  are  also  causes  of 
hemorrhage. 


LABOR.  181 

What  are  the  symptoms  ? 

As  a  rule,  there  are  no  precursory  symptoms.  In  some  cases, 
however,  there  may  be  a  slight  increase  in  the  rate  of  the  pulse, 
the  patient  being  restless,  and  complaining  of  thirst.  The  hemor- 
rhage usually  comes  on  suddenly  and  without  warning.  It  may 
be  internal  or  external,  usually  both.  Palpating  over  the  abdomen 
the  examining  hand  no  longer  feels  a  hard,  round,  resisting  body, 
but  the  uterus  is  found  enlarged,  soft,  and  relaxed.  In  some  cases 
it  is  impossible  to  outline  the  uterus.  The  patient,  unless  treat- 
ment be  promptly  resorted  to,  rapidly  sinks,  and  dies  from  the  loss 
of  blood. 

What  are  the  indications  for  treatment? 

1.  To  Lower  the  Patients  Head. — Take  away  the  pillow  and  bolster 
and  raise  the  foot  of  the  bed. 

2.  To  Excite  Uterine  Contractions. — The  most  prompt  and  efficient 
method  is  the  injection  of  hot  water  (110°  F.)  directly  into  the 
cavity  of  the  uterus  by  means  of  the  Davidson  or  fountain  syringe. 
While  waiting  for  the  hot  water  and  syringe  introduce  one  hand 
into  the  cavity  of  the  uterus,  and  with  the  other  make  pressure 
upon  the  abdomen,  thus  compressing  the  uterus  between  the  two 
hands.  A  better  plan,  however,  is  to  throw  the  uterus  into  a 
position  of  strong  anteflexion  (Breisky's  method).  This  is  accom- 
plished by  introducing  one  hand  into  the  vagina,  carrying  it  up- 
ward into  the  posterior  cul-de-sac,  and  fixing  the  lower  uterine 
segment.  The  other  hand  is  pressed  deep  down  through  the 
abdominal  v/alls  behind  the  fundus,  which  is  then  pushed  forward 
as  far  as  possible.  While  uterine  contractions  are  being  excited  a 
hypodermatic  injection  of  ergot  should  be  given  by  an  assistant. 

3.  To  Overcome  the  Immediate  Effects  of  the  Hemorrhage. — Sul- 
phuric ether  should  be  given  hypodermatically,  and  compression 
made  upon  the  abdominal  aorta.  The  blood  may  also  be  forced 
out  of  the  lower  extremities  into  the  heart  and  brain  by  means  of 
bandages  (auto-transfusion).  It  may  also  be  necessary  to  resort  to 
transfusion  of  blood,  or  milk,  or  saline  solution.  Grandin  advises 
the  following  formula :  Chloride  of  sodium  60  grains,  chloride  of 
potass.  6  grains,  phosphate  of  soda  3  grains,  carbonate  of  soda  20 
grains,  distilled  water  to  20  ounces,  the  whole  heated  to  90°  F. 


182  ESSENTIALS    OF    OBSTETRICS. 

4.  Other  Means  to  Excite  Uterine  Contractions. — The  faradic  cur- 
rent is  one  of  the  most  scientific  and  prompt  means  to  stimulate 
contractions  of  the  uterus.  A  small  pocket  battery,  which  can  be 
conveniently  carried,  will  answer  all  indications.  Among  other 
remedies  may  be  mentioned  the  application  of  cold,  either  in  the 
form  of  ice  applied  to  the  abdomen  or  introduced  into  the  uterus, 
and  the  injection  into  the  uterine  cavity  of  salts  of  iron.  A  pocket- 
handkerchief  saturated  with  vinegar  and  carried  up  into  the  uterine 
cavity  is  strongly  recommended  by  Penrose. 

What  is  the  after-treatment  of  post-partum  hemorrhage? 

This  consists  in  the  administration  of  opium  and  ergot.  The 
diet  should  be  nourishing,  and  at  first  given  in  small  quantities. 
If  the  stomach  rejects  food,  nutrient  enemata  are  called  for.  In 
some  cases  alcohol  in  some  form  is  indicated.  Compression  of  the 
uterus  should  be  made  by  means  of  towels  as  described  in  the 
chapter  on  the  conduct  of  labor. 

Secondary  Hemorrhage. 

What  are  the  causes  of  secondary   post-partum  hemor- 
rhage ? 

The  causes  already  given  for  primary  may  also  produce  secondary 
hemorrhage.  Usually,  however,  a  secondary  hemorrhage  is  due  to 
a  retention  of  a  part  of  the  placenta  or  membranes,  or  to  a  pla- 
centa succenturiata.  Sometimes  a  displacement  of  the  uterus  will 
give  rise  to  the  disorder. 

What  is  the  treatment  ? 

The  routine  treatment  is  the  same  as  that  already  described  for 
a  primary  hemorrhage.  Correct  any  displacement  of  the  uterus 
which  may  exist  as  a  cause,  or  empty  the  uterine  cavity  of  any 
foreign  substances  which  it  may  contain.  Ergot  should  be  given 
for  several  days.  The  after-treatment  is  the  same  as  that  of 
primary  hemorrhage. 

Puerperal  Septicaemia. 

What  is  puerperal  septicaemia  ? 

"An  acute  febrile  affection,  heterogenetic  and  contagious,  attack- 
ing women  in  childbirth." 


LABOR.  183 

What  is  the  cause  of  septicssmia  ? 

The  septic  inoculation  of  wounds  of  the  uterus  or  vulvo-vaginal 
canal  by  a  poison  introduced  from  without,  the  exact  nature  of 
which  is  not  known. 

Why  is   septicaemia   more   frequent    during   the   winter 
season? 

On  account  of  a  want  of  personal  cleanliness  and  proper  ven- 
tilation. 

Why  is  septicsemia  more  frequent  in  primiparse  ? 

Because  the  labor  is  longer,  there  is  more  interference  on  the 
part  of  the  accoucheur,  and  also  on  account  of  the  greater  liability 
to  tears  of  the  soft  parts. 

Under  how  many  forms  may  septicaemia  be  studied? 
Three :  1,  benign  form  ;  2,  grave  form  ;  3,  late  form. 

Describe  the  symptoms  and  course  of  the  benign  form. 

Time  of  Occurrence. — It  usually  begins  about  the  third  day ;  it 
may  be  later  or  earlier. 

Chill. — As  a  rule,  the  disease  begins  with  a  chill,  more  or  less 
severe. 

Fever. — The  chill  is  followed  by  a  fever,  the  temperature  reach- 
ing 104°  F.,  or  higher;  it  then  falls  to  102.5°.  The  temperature 
remains  at  this  point,  with  an  evening  raise,  for  seven  to  ten  days. 

Lochia. — The  flow  is  diminished  or  arrested,  and,  as  a  rule, 
offensive. 

The  Secretion  of  Milk. — The  secretion  of  milk  is  lessened  or 
arrested.  It  is  prevented  if  the  disease  begins  before  the  third 
day. 

Pain. — Severe  pain  is  felt  on  pressure  in  the  lower  portion  of  the 
abdomen. 

Uterus. — There  is  an  arrest  of  involution  ;  the  uterus  being  large 
and  soft.  In  some  cases  a  swelling  may  be  felt  at  the  side  of  the 
uterus. 

Stomach. — There  is  usually  an  irritable  condition  of  the  stomach, 
with  nausea  and  vomiting. 

Boiveh. — As  a  rule,  constipation  exists. 

Urine. — No  albumen. 


184  ESSENTIALS    OF    OBSTETKICS. 

Describe  the  symptoms  and  course  of  the  grave  form. 

Time  of  Occurrence. — As  a  rule,  the  disease  begins  within  the 
first  two  days. 

Chill. — Usually  occurs. 

Fever. — The  temperature  reaches  104°  or  106°  F.  The  morning 
decline  in  the  temperature  is  slight  or  absent. 

Abdomen. — The  intestines  become  distended  with  gas.  Pressure 
upon  the  abdomen  causes  severe  suffering. 

Respiration. — The  breathing  is  frequent  and  shallow,  due  to 
pressure  upon  the  diaphragm  from  below. 

Tongue. — The  tongue  is  cracked  and  parched,  and  the  thirst  ex- 
cessive. 

Stomach. — There  is  nausea  and  vomiting. 

Urine. — As  a  rule,  contains  albumen.  It  is  scanty  and  high- 
colored. 

Pulse. — The  pulse  varies  from  100  to  150  or  more. 

Bowels. — Diarrhoea  is  frequent,  the  discharges  becoming  later  on 
offensive  and  dark  in  color.  The  diarrhoea  may  become  so  profuse 
that  the  patient  sinks  into  a  condition  of  collapse. 

Appearance  of  the  Shin. — Jaundice  may  occur  toward  the  end  of 
the  disease. 

Termination. — The  mind,  as  a  rule,  remains  clear  to  the  last. 
Death  may  terminate  the  disease  within  thirty-six  hours,  but 
usually  it  is  delayed  for  several  days  (from  five  to  ten). 

Describe  the  symptoms  and  course  of  the  late  form. 

Time  of  Occurrence. — Usually  begins  in  four  or  five  days  after 
delivery,  but  it  may  not  make  its  appearance  for  several  weeks. 

Chill. — The  disease  begins  with  a  chill,  more  or  less  pronounced. 

Fever. — The  temperature  reaches  104°  F.,  or  even  higher.  It 
then  falls  to  almost  normal,  followed  by  perspiration. 

Lochia. — Normal,  or  somewhat  deranged. 

Urine. — A  small  trace  of  albumen. 

Abdomen. — There  is  no  pain  or  swelling ;  decided  pressuie  in 
many  cases  fails  to  elicit  tenderness. 

Termination. — Day  after  day,  and  week  after  week,  the  chills 
recur,  followed  by  a  rise  in  the  temperature.  There  is,  however, 
no  regularity  in  their  occurrence.     Finally  the  disease  ends  either 


LABOR. 


185 


in  convalescence  and  recovery,  or  the  patient  may  pass  into  a 
typhoid  state. 

The  disease  may  be  mistaken  for  malarial  fever. 

What  is  the  diagnosis  between  septic  lymphangitis  and 
septic  phlebitis  ? 


lAjmphangitis. 
Begins  early. 
Chill  more  or  less  severe. 

Temperature  uniform . 

Always  extends  upward. 

Lymphatic  glands  involved. 

The  disease  becomes  localized. 

Peritoneal  abscesses. 

Abdomen  painful. 

Abdomen  swollen. 

Tumor  or  swelling  at  the  side  of 

the  uterus. 
Constipation. 
Lochia  offensive. 


Phlebitis. 

Begins  late. 

Chill  severe,  and  recurs  at  irreg- 
ular intervals. 
Temperature,   great   variations 
associated  with  perspiration. 

The  distribution  of  the  poison 
is  general. 

Not  involved. 

Usually  extends. 

General  abscesses. 

Abdomen  not  painful. 

Abdomen  not  swollen. 

No  tumor  or  swelling. 

Diarrhoea. 
Lochia  offensive. 


How  is  the  treatment  of  septicaemia  divided  ? 

Into :  1.  The  prophylactic  treatment. 
2.  The  curative  treatment. 
a.  Essential  or  local. 
h.  Symptomatic  or  constitutional. 

Describe  the  prophylactic  and  curative  treatment  of  septi- 
caemia. 

Prophylaxis. — This  subject  has  been  sufficiently  discussed  in 
the  chapter  on  Antisepsis. 

Essential  oe,  Local  Treatment. — This  consists  in  eradicat- 
ing the  source  of  the  poison  by  means  of  antiseptics. 

Antiseptics  employed.  Corrosive  sublimate  is  the  most  efficient 
antiseptic  in  use.     For  vaginal  injections  it  should  be  used  in  a 


186  ESSENTIALS    OF    OBSTETRICS. 

solution  of  1  part  to  2000 ;  for  uterine,  1  part  to  3000.  Carbolic 
acid  is  a  remedy  upon  whicli  but  little  reliance  can  be  placed,  and 
it  should  never  be  used,  except  as  a  substitute  for  corrosive  sub- 
limate in  case  symptoms  of  poisoning  with  the  latter  drug  mani- 
fest themselves ;  a  three  or  five  per  cent,  solution  should  be  used 
for  vaginal  or  uterine  irrigation. 

Precautions  against  poiso7iing  with  antiseptics.  The  vagina  or 
uterus  should  be  freely  washed  out  with  warm  distilled  water  after 
the  use  of  an  antiseptic  injection. 

Means  for  employing  injections.  For  vaginal  injections  use  a 
fountain  or  Davidson  syringe.  For  uterine  irrigation  use  Boze- 
man's  catheter,  attached  to  a  fountain  or  Davidson  syringe; 
Chamberlain's  glass  tube,  or  an  ordinary  soft  catheter,  will 
answer  perfectly  well.  In  case  of  necessity,  the  nozzle  of  a  foun- 
tain or  Davidson  syringe  may  be  used.  In  using  intra-uterine 
injections  care  should  be  taken  to  guard  against  the  entrance  of 
air. 

Frequency  of  antiseptic  injections.  Their  frequency  depends  upon 
the  indications.  Usually  they  are  to  be  given  twice  in  the  twenty- 
four  hours.  In  some  cases  it  may  be  necessary  to  employ  them 
more  frequently,  three  times  or  oftener  in  the  twenty-four  hours. 

Indications  for  local  treatment.  Elevation  of  the  temperature, 
unless  dependent  upon  inflammation  of  the  breast  or  of  the  nipple, 
and  offensive  lochia.  The  absence  of  a  chill  is  not  a  contra-indi- 
cation. 

The  above  symptoms  call  for  vaginal  injections,  which  should  be 
continued  for  twenty-four  hours,  when  intra-uterine  irrigation 
should  be  employed,  unless  the  temperature  declines  and  the 
character  of  the  lochia  changes.  If  the  temperature  and  lochia 
show  no  improvement  after  twenty-four  or  forty-eight  hours,  the 
uterus  should  then  be  emptied  of  fragments  by  means  of  Emmet's 
curette  forceps,  or  the  dull  wire  curette,  and  the  intra-uterine 
antiseptic  injections  continued. 

Symptomatic  or  Constitutional  Treatment. — High  tem- 
perature. The  drugs  usually  employed  to  reduce  the  temperature 
are,  salicylate  of  soda,  salicylic  acid,  quinine,  whiskey,  and  anti- 
pyrine. 

Salicylate  of  soda  is  preferred  to  salicylic  acid;  either  drug 


LABOR.  187 

should  be  given  in  doses  of  ten  to  twenty  grains,  every  four  hours ; 
if  after  four  doses  have  been  administered,  the  temperature  does 
not  decline,  the  treatment  should  be  changed. 

Quinine  may  be  given  either  by  the  mouth  or  by  the  rectum,  in 
doses  often  to  fifteen  grains,  three  times  in  the  twenty-four  hours. 

Alcohol  is  especially  indicated  as  a  tonic  and  antipyretic  in 
grave  cases.  It  should  be  given  in  milk  at  regular  intervals ;  the 
quantity  used  in  the  twenty-four  hours  varies  from  eight  to  sixteen 
ounces. 

Antipyrine  may  be  given  in  a  dose  of  ten  or  fifteen  grains. 
Usually  within  an  hour  or  two  the  temperature  declines  ;  if,  how- 
ever, this  reduction  does  not  occur,  the  dose  may  be  repeated. 

Pain.  Opium  may  be  given  by  the  mouth,  or  hypodermatically, 
or  by  the  rectum.  It  should  be  given  in  large  doses  if  peritonitis 
is  present. 

Sleeplessness.     Give  opium,  chloral,  or  bromide  of  potassium. 

Vomiting.  Use  small  quantities  of  hot  water  at  frequent  inter- 
vals, lime  water,  ice,  or  champagne.  Counter-irritation  to  the 
epigastrium  and  hypodermatic  injections  of  morphia  are  also 
useful. 

Intestinal  tympanites.  Use  strychnia  in  the  form  of  nux  vomica, 
rectal  injections  of  salt  water,  cold  applications  to  the  abdomen, 
the  introduction  of  the  rectal  tube,  turpentine  stapes,  or,  finally, 
capillary  puncture  of  the  intestines. 

Bowels.  A  free  action  of  the  bowels  should  be  kept  up.  Give 
either  an  enema  of  salt  and  water  or  a  mild  laxative.  The  use  of 
calomel  is  highly  recommended  by  Dr.  J.  C.  Da  Costa  ;  he  advises 
at  first  a  decided  dose  (five  to  ten  grains)  to  be  given,  followed  by 
smaller  doses  (one-quarter  to  one -half  of  a  grain)  repeated  every 
hour  until  the  bowels  are  freely  moved. 

Food.  The  patient  should  be  given  nourishing  and  easily  di- 
gestible food,  such  as  beef- tea,  milk,  broths,  etc. 

Indication  for  abdominal  section.  When  the  effusion  into  the 
peritoneal  cavity  "  is  chiefly  liquid." 


188  ESSENTIALS    OF    OBSTETRICS. 

OBSTETRIC  OPERATIONS. 

The  Induction  of  Premature  Labor. 

What  are  the  indications  ? 

The  induction  of  premature  labor  is  justifiable  in  cases  in  which 
the  life  of  the  mother  or  child,  or  both,  are  in  danger,  from  the 
further  continuance  of  pregnancy  or  delivery  at  term. 

1.  1)1  the  Interests  of  the  Child. 

a.  Habitually  large  size  of  the  foetus,  and  premature  ossifica- 

tion of  the  foetal  head. 

b.  Habitual  death  of  the  foetus  in  the  latter  part  of  pregnancy. 

c.  Pelvic  deformity  and  neoplasms. 

2.  In  the  Interests  of  the  Mother. 

Among  the  conditions  requiring  the  induction  of  premature  labor 
may  be  mentioned  the  following :  Uterine  hemorrhage  (accidental 
and  unavoidable) ;  hyperemesis ;  acute  and  chronic  affections  of 
the  heart  and  lungs ;  polyhydramnios;  ascites;  abdominal  tumors ; 
albuminuria ;  eclampsia ;  and  chorea. 

How  may  we  arrive  at  a  probable  conclusion  as  to  the  size 
of  the  foetus  ? 

1.  A  history'of  large  children  in  previous  pregnancies. 

2.  The  health  and  size  of  the  mother. 

3.  The  size  of  the  father. 

4.  The  period  of  the  woman's  sexual  life ;  children  born  early 
or  late  in  life  are  not  as  large  as  those  born  during  the  intervening 
period. 

5.  The  number  of  previous  pregnancies :  the  size  of  the  foetus 
increases  with  the  number  of  births. 

What  is  the  best  time  to  induce  premature  labor  ? 

1.  Habiiually  Large  Size  of  the  Foetus. — One  or  two  weeks  before 
full  term. 

2.  Habitual  Death  of  the  Foetus  in  the  Latter  Part  of  Pregnancy. — 
Before  the  period  at  which,  according  to  previous  experience,  the 
death  of  the  foetus  is  expected.  The  operation  is  not  indicated  in 
habitual  death  of  the  foetus  from  syphilis  or  organic  diseases. 


OBSTETRIC    OPERATIONS.  189 

3.  Pelvic  Deformity  and  Neoplas7ns.—The  following  table  is  taken 
from  Charpentier : 

a.  Pelvis  of  3.5  inches.     In  a  multipara  labor  should  be  in- 

duced at  eight  months  one  week,  to  eight  and  a  half 
months.  In  primipara  wait  until  term,  or,  at  least,  do 
not  induce  labor  till  eight  or  ten  days  before  term. 

b.  Pelvis  of  3.3  inches.     At  eight  months  to  eight  and  a  half. 

c.  Pelvis  of  3.1  inches.     Between  eight  and  eight  and  a  half 

months. 

d.  Pelvis  of  2.9  inches.     Between  seven  and  a  half  and  eight 

months. 

e.  Pelvis  of  2.7  inches.     Between  seven  months  and  seven 

months  three  weeks. 
/.  Pelvis  2.5  to  2.3  inches.     At  seven  to  seven  and  a  half 

months. 
Below  2.3  inches,  abortion  should  be  induced.     All  of  the 

above  measurements  refer  to  the  antero-posterior  diameter 

of  the  inlet. 

4.  In  the  Interests  of  the  Mother.— The  condition  of  the  mother 
necessarily  determines  the  time  of  inducing  labor.  The  longer 
the  operation  is  delayed,  however,  the  more  favorable  the  prog- 
nosis for  the  foetus.  The  child  is  viable  at  the  end  of  the  seventh 
month,  but  the  period  of  viability  is  now  placed  earlier,  since  arti- 
ficial feeding  (gavage)  has  enabled  children  to  live  who  were  born 
prior  to  that  time. 

What  is  the  prognosis  in  the  induction  of  labor  ? 

The  prognosis  should  be  guarded;  it  is  unnatural  and  the 
liability  to  puerperal  diseases  is  greater. 

What  are  the  methods  in  use  for  inducing  labor  ? 

1.  The  Introduction  of  cm  Elastic  Bougie,  or*Catheter,  between  the 
Membranes  and  the  Walls  of  the  Uterus.— The  bougie  is  carefully 
introduced  until  the  instrument  is  almost  entirely  within  the 
uterine  cavity,  and  allowed  to  remain  until  the  os  is  dilated.  A 
tampon  is  rarely  necessary  to  keep  the  bougie  in  position.  By 
leaving  two  inches  of  the  end  of  the  instrument  outside  the  cervix 
it  rests  upon  the  vaginal  wall  and  prevents  the  bougie  from  slip- 
ping out  of  the  uterus.     In  primiparse  it  may  be  necessary,  in  some 


190  ESSENTIALS    OF    OBSTETEICS. 

cases,  to  dilate  the  cervix  with  a  tupelo  or  sea-tangle  tent,  before 
resorting  to  the  bougie ;  or  vaginal  douches  may  be  employed. 
Labor  usually  follows  the  introduction  of  the  bougie  in  the  course 
of  a  few  hours.  Should  labor  not  occur  within  forty-eight  hours 
some  other  method  should  be  employed. 

2.  Artificial  Dilatation  of  the  Cervix. 
a.  Barnes's  dilators. 

h.  Tarnier's  dilator. 

Tupelo  or  sea-tangle  tents  are  resorted  to  as  preparatory  to 
other  means. 

3.  Douches. — Use  a  fountain  syringe  holding  a  gallon  of  water, 
at  a  temperature  of  106°  F.  At  first  use  three  douches  in  the 
twenty-four  hours ;  each  injection  lasting  from  ten  to  fifteen 
minutes.  Later  on  the  number  and  duration  of  the  injections 
depend  upon  the  eflTect  produced,  and  upon  the  rapidity  with 
which  delivery  is  to  be  accomplished.  The  number  of  douches 
required  depends  upon  the  case;  usually  twelve  injections  are  all 
that  are  necessary.  "  The  douche  acts  by  the  warmth  of  the  water, 
by  stimulation  of  the  lower  uterine  segment,  and  by  dilatation  of 
the  vagina.'' 

4.  Rupture  of  the  Membranes. 

How  would  you  induce  labor  in  an  ordinary  case  ? 

Give  a  vaginal  injection  in  the  afternoon,  followed  by  the  intro- 
duction of  a  bougie,  which  is  left  in  the  uterus  over  night.  If 
necessary,  repeat  the  injection  next  morning;  usually,  however, 
within  twenty-four  hours  the  cervix  is  soft  and  dilatable.  Barnes's 
dilators  should  now  be  used  to  complete  the  dilatation.  The  sub- 
sequent care  of  the  case  depends  upon  circumstances  ;  as  a  rule, 
the  case  is  left  to  nature.  Occasionally,  however,  the  delivery  is 
accomplished  by  version,  or  the  use  of  the  forceps. 


The  Induction  of  Abortion. 

What  are  the  indications  ? 

The  induction  of  abortion  is  justifiable  whenever  the  operation 
offers  the  only  chance  of  saving  the  life  of  the  mother. 


OBSTETRIC    OPERATIONS.  191 

1.  Diseases  of  the  Mother  dependent  upon  Pregnancy, — Hyperemesis 
is  one  of  the  most  frequent  indications. 

2.  Diseases  of  the  Mother  independent  of  Pregnancy. — Diseases  of 
the  heart,  lungs,  and  kidneys,  when  the  symptoms  are  peculiarly 
grave,  may  be  mentioned  as  among  the  indications. 

3.  Obstruction  of  the  Birth-canal,  due  either  to  Pelvic  Deformity  or 
Neoplasms. — In  cases  of  extreme  pelvic  narrowing,  the  woman  may 
elect  either  the  induction  of  abortion  or  Csesarean  section. 

4.  Uterine  Displacements. — Eetroversion  or  retroflexion,  with  in- 
carceration, and  cases  of  procidentia  which  are  irreducible. 

5.  Diseases  of  the  Ovum. 

What  is  the  best  time  to  induce  abortion? 

If  the  induction  of  abortion  be  decided  upon  for  disease,  the 
time  is,  of  course,  a  secondary  consideration ;  the  condition  of  the 
patient  is  of  first  importance.  The  best  time  to  induce  abortion  is 
during  the  first  two  months,  or  after  the  fifth.  It  is  between  these 
periods  that  serious  hemorrhage  and  retention  of  secundines  are 
likely  to  occur.  If  the  operation  is  indicated  on  account  of  pelvic 
deformity,  the  following  table,  taken  from  Lusk,  will  guide  us  as 
to  the  latest  period  it  may  be  performed : 

Antero-posterior  diameter  ^  Latest  period  for  inducing 

of  pelvis.  abortion. 

One  and  a  half  inch.  Beginning  of  sixth  month. 

One  and  a  quarter  inch.  Beginning  of  fifth  month. 

One  inch.  Four  mouths  and  a  half. 

What  is  the  prognosis  ? 

Generally  good ;  however,  it  depends  upon  the  condition  of  the 
patient,  and  the  cause. 

What  are  the  methods  in  use  for  inducing  abortion  ? 

1.  Tupelo,  or  sea-tangle  tents,  introduced  into  the  cervical  canal. 

2.  Puncturing  the  membranes  with  a  uterine  sound. 

3.  Medicines,  electricity,  intra-uterine  injections,  etc. 

In  late  abortions,  i.  e.,  after  the  fifth  month,  the  methods  are  the 
same  as  already  described  in  the  chapter  on  the  induction  of  pre- 
mature labor. 


192  ESSENTIALS    OF    OBSTETRICS. 

Version,  or  Turning. 

What  is  version? 

Version  is  an  operation  by  means  of  which  one  presenting  foetal 
part  is  changed  for  another. 

How  is  version  divided  ? 

Into  1.  Cephalic  version,  or  the  substitution  of  the  head  for  the 
shoulder  or  pelvis. 

2.  Pelvic  version,  or  the  substitution  of  the  breech  for  the  shoulder 
or  head. 

3.  Podalic  version,  or  the  bringing  down  of  one  or  both  feet; 
this  operation  is  a  variety  of  pelvic  version. 

Cephalic  Version. 

What  are  the  methods  of  performing  cephalic  version  ? 

1.  Internal  and  external  version. 

2.  External  version. 

Describe  the  operation  of  version  by  the  internal  and  ex- 
ternal methods. 

1.  Wright's  Method. — "Suppose  the  patient  to  have  been  placed 
upon  her  back,  across  the  bed,  and  with  her  hips  near  its  edge,  the 
presentation  to  be  the  right  shoulder,  with  the  head  in  the  left  iliac 
fossa,  the  right  hand  to  have  been  introduced  into  the  vagina,  and 
the  arm,  if  prolapsed,  having  been  placed  as  near  as  may  be  in  its 
original  position,  across  the  breast.  We  now  apply  our  fingers 
upon  the  top  of  the  shoulder,  and  our  thumb  in  the  opposite  axilla, 
or  on  such  part  as  will  give  us  command  of  the  chest,  and  enable 
us  to  apply  a  degree  of  lateral  force.  Our  left  hand  is  also  applied 
to  the  abdomen  of  the  patient,  over  the  breech  of  the  foetus. 
Lateral  pressure  is  made  upon  the  shoulders  in  such  a  way  as  to 
give  the  body  of  the  foetus  a  curvilinear  movement.  At  the  same 
time,  the  left  hand,  applied  as  above,  makes  pressure,  so  as  to  dis- 
lodge the  breech,  as  it  were,  and  move  it  toward  the  centre  of  the 
uterine  cavity.  The  body  is  thus  made  to  assume  its  original  bent 
position,  the  points  of  contact  with  the  uterus  are  loosened,  and 


OBSTETRIC    OPERATIONS.  193 

perhaps  diminished,  and  the  force  of  adhesion  is  in  a  good  degree 
overcome.  Without  any  direct  action  upon  the  head,  it  gradually 
approaches  the  superior  strait,  falls  into  the  opening,  and  will,  in 
all  probability,  adjust  itself  as  a  favorable  vertex  presentation.  If 
not,  the  head  may  be  acted  upon  as  in  deviated  positions  of  the 
vertex,  or  it  may  be  grasped,  brought  into  the  strait,  and  placed  in 
correspondence  with  one  of  the  oblique  diameters." 

2.  Braxton  Hicks' s  Method. — ''  Introduce  the  left  hand  into  the 
vagina,  as  in  podalic  version,  place  the  right  hand  on  the  outside 
of  the  abdomen,  in  order  to  make  out  the  position  of  the  foetus, 
and  the  direction  of  the  head  and  feet.  Should  the  shoulder,  for 
instance,  present,  then  push  it  with  one  or  two  fingers  on  the  top, 
in  the  direction  of  the  feet.  At  the  same  time  pressure  by  the  outer 
hand  should  be  exerted  on  the  cephalic  end  of  the  child.  This 
will  bring  down  the  head  close  to  the  os;  then  let  the  head  be 
received  upon  the  tips  of  the  inside  fingers.  The  head  will  play 
like  a  ball  between  the  two  hands,  it  will  be  under  their  command, 
and  can  be  placed  in  almost  any  part  at  will.  Let  the  head  then 
be  placed  over  the  os,  taking  care  to  rectify  any  tendency  to  face 
presentation.  It  is  as  well,  if  the  breech  will  not  rise  to  the  fundus 
readily  after  the  head  is  fairly  in  the  os,  to  withdraw  the  hand  from 
the  vagina,  and  with  it  press  up  the  breech  from  the  exterior.  The 
hand  while  retaining  gently  the  head  from  the  outside,  should 
continue  there  for  some  little  time,  till  the  pains  have  insured 
the  retention  of  the  child  in  its  new  position  by  the  adaptation  of 
the  uterine  walls  to  its  form." 

What   are   the  conditions  necessary  for   version  by  the 
internal  and  external  methods  ? 

1.  Foetus  movable  in  utero ;  the  membranes  may  or  may  not  be 
intact. 

2.  The  cervix  dilated  or  dilatable ;  Hicks's  method  is  available 
when  the  os  is  but  slightly  dilated. 

What  are  the  indications  for  version  by  the  internal  and 
external  methods  ? 

For  the  safety  of  the  mother  or  child,  or  both. 

a.  Transverse  presentations. 

b.  Accidental  or  unavoidable  hemorrhage. 

13 


194  ESSENTIALS    OF    OBSTETRICS. 

c.  Cases  of  contracted  pelves. 

d.  Prolapse  of  the  cord. 

Describe  the  operation  of  version  by  the  external  method. 
Suppose  the  position  of  the  shoulder  to  be  a  E.  D.  A.,  i.  e.,  the 
head  in  the  left  iliac  fossa  and  the  breech  upon  the  opposite  side. 
The  obstetrician  standing  on  the  right  side  of  the  patient,  places 
his  right  hand  upon  the  foetal  head,  while  his  left  makes  pressure 
upon  the  breech.  The  pressure  upon  the  foetal  head  is  directed 
downward  toward  the  pelvic  inlet,  while  the  breech  is  pushed  up- 
ward toward  the  fundus  of  the  uterus.  When  the  head  has  been 
brought  to  the  inlet,  the  patient  is  placed  upon  her  left  side,  and 
if  labor  has  begun  the  membranes  are  ruptured  ;  if  labor  has  not 
begun,  then  a  compress  and  bandage  should  be  applied. 

When  may  external  version  be  performed  ? 

1.  In  the  latter  part  of  pregnancy. 

2.  In  the  beginning  of  labor. 

What  are  the  most  important  indications  ? 

Transverse  presentations  of  the  foetus.  It  is  also  advised  by 
some  authorities  in  breech  presentations.  However,  we  do  not 
recommend  the  operation  under  these  circumstances,  as  it  is  useless 
in  multiparas,  while  in  primiparse,  where  cephalic  version  would 
be  indicated,  it  is,  as  a  rule,  impossible  to  perform. 

What  are  the  conditions  necessary  for  version  by  the  external 
method  ? 

1.  The  diagnosis  must  be  certain. 

2.  The  uterus  must  not  be  irritable. 

3.  The  foetus  must  be  movable ;  as  a  rule,  the  membranes  must 
be  unruptured. 

Pelvic  Version. 

When  may  pelvic  version  be  performed  ? 

1.  In  the  latter  part  of  pregnancy. 

2.  During  labor. 


OBSTETKIC    OPEKATIONS.  195 

What  are  the  methods  of  performing  pelvic  version  ? 

1.  The  external  method. 

2.  The  internal  and  external  methods. 

The  operation  by  the  external  method  is  similar  to  that  em- 
ployed in  cephalic  version.  Parvin  succeeded  in  changing  a 
shoulder  presentation  to  that  of  a  breech,  by  placing  the  woman 
in  the  knee-chest  position,  and,  at  the  same  time,  making  pressure 
upon  the  shoulder. 

Version  by  the  internal  and  external  methods  is  accomplished 
by  introducing  one  or  two  fingers  into  the  uterus  and  pushing  upon 
the  presenting  part,  while  the  other  hand,  placed  externally, 
directs  the  head  toward  the  fundus. 

When  is  pelvic  version  indicated  ? 

External  version  is  indicated  whenever  the  breech  lies  closer  to 
the  pelvic  inlet  than  the  head.  The  operation,  however,  is  rarely 
employed,  as  cephalic  version  may  be  performed  in  most  cases. 

Version  by  the  internal  and  external  methods  is  indicated  in 
neglected  shoulder  presentations  ;  or  it  may  be  employed  as  a  pre- 
liminary step  in  podalic. 

Podalic  Version. 

What  are  the  indications  for  podalic  version  1 

1.  Transverse  or  oblique  positions,  where  cephalic  version  can- 
not be  performed,  or  is  contraindicated. 

2.  Conditions  which  endanger  the  life  of  the  mother— for  in- 
stance : 

a.  Hemorrhage. 

b.  Eclampsia. 

c.  Eupture  of  the  uterus. 

3.  Conditions  which  endanger  the  life  of  the  child— for  in- 
stance : 

a.  Certain  face  presentations. 

b.  Prolapse  of  the  cord. 

c.  Pelvic  tumors. 

4.  Pelvic  deformity. 


196  ESSENTIALS    OF    OBSTETKICS. 

What  are  the  methods  of  performing  podalic  version  ? 

1.  The  bi-polar  method  of  Braxton  Hicks. 

2.  Internal  version — i.e.,  the  introduction  of  the  entire  hand 
into  the  uterine  cavity. 

What  are  the  conditions  necessary  for  version  by  Hicks's 
method  ? 

1.  Slight  dilatation  of  the  cervix. 

2.  Mobility  of  the  foetus ;  the  operation,  although  more  difficult, 
is  not  always  impracticable  after  rupture  of  the  membranes. 

3.  A  positive  diagnosis  as  to  the  position  of  the  foetus. 

Describe  Hicks's  method  of  performing  podalic  version. 

Place  the  patient  upon  her  side  or  upon  her  back ;  the  latter 
position  is  the  one  most  generally  adopted  in  this  country.  The 
bladder  and  rectum  should  be  emptied.  The  patient  should  be 
under  anaesthesia.  The  hand  selected  for  internal  manipulation 
should  correspond  in  name  to  the  side  of  the  j)elvis  toward  which 
the  feet  of  the  foetus  are  directed.  Two  or  three  fingers  are  intro- 
duced through  the  internal  os,  while  the  other  hand  is  placed  on 
the  abdomen,  the  former  making  pressure  directly  upon  the  pre- 
senting part,  while  the  latter  is  applied  to  the  breech  directing  it 
down  toward  the  pelvic  cavity.  When  the  breech  has  been 
brought  down  the  membranes  should  be  ruptured  during  a  uterine 
contraction.  After  the  contraction  ceases  seize  a  knee  and  bring 
it  down  into  the  vagina,  while,  at  the  same  time,  the  external  hand 
presses  the  head  of  the  foetus  toward  the  fundus  of  the  uterus. 
If  a  knee  cannot  be  reached,  make  pressure  upon  some  portion  of 
the  breech,  or  hook  a  finger  into  the  fold  of  the  thigh  and  bring 
the  pelvis  down. 

What   are   the   conditions  necessary  for  version  by  the 
internal  method  ? 

1.  The  cervix  should  be  dilated. 

2.  The  presenting  part  should  not  have  become  fixed. 

3.  The  pelvis  must  be  large  enough  to  allow  the  foetus  to  be 
delivered  after  turning. 


OBSTETRIC    OPERATIONS. 


197 


Describe  the  internal  method  of  performing  podalic  version. 
Have  the  bladder  and  rectum  emptied ;  the  patient  under  anaes- 
thesia ;  her  buttocks  over  the  edge  of  the  bed,  her  feet  placed 
upon  chairs,  and  her  knees  supported  on  each  side  by  an  assistant. 
The  operator  either  sits  or  stands  between  the  thighs  of  the 
patient.  During  the  interval  of  a  uterine  contraction,  the  hand, 
formed  into  a  cone,  is  introduced  into  the  vagina  and  is  then 
passed  up  to  the  os  uteri,  at  the  same  time  making  counter-pres- 


FiG.  9, 


7'  ,/'- 


Grasping  the  feet  in  podalic  version. 

sure  upon  the  fundus  with  the  external  hand.  If  the  membranes 
are  intact  rupture  them,  and  introduce  the  hand  at  once  into  the 
uterus  preventijig  as  much  as  possible  the  escape  of  the  liquor  amnii. 
While  searching  for  the  feet  or  for  a  foot,  fix  the  position  of  the 
foetus  by  making  pressure  upon  the  fundus  of  the  uterus  with  the 
other  hand.  To  find  the  feet,  pass  the  hand  directly  to  the  ante- 
rior plane  of  the  foetus,  or  follow  the  lateral  plane  until  the  lower 
extremities  are  found.  Having  reached  the  knee  or  foot,  traction 
is  to  be  made  and  the  member  brought  down  into  the  vagina.    As 


198  ESSENTIALS    OF    OBSTETEICS. 

a  rule,  it  is  better  to  bring  down  only  one  leg,  as  the  subsequent 
dilatation  of  the  cervix  is  more  complete,  and  there  is  less  danger 
to  the  child  from  pressure  upon  the  cord.  As  soon  as  the  leg  is 
brought  down,  into  the  vagina,  place  a  noose  of  thick  muslin 
around  it  and  continue  the  traction.  If  the  head  cannot  be  dis- 
lodged by  traction  on  the  leg,  assisted  by  external  pressure,  then 
introduce  the  hand  into  the  vagina  and  push  it  up.  If  both  feet 
are  brought  down,  they  are  grasped  by  the  operator  and  traction 
made,  assisted,  at  the  same  time,  by  external  pressure.  If  an  arm 
be  prolapsed,  it  is  not  necessary  in  all  cases  to  return  it.  Place  a 
noose  around  the  wrist  so  as  to  prevent  its  ascension  along  the  side 
of  the  head.  In  most  cases,  after  version  has  been  accomplished, 
leave  the  case  to  Nature,  as  in  pelvic  presentations.  If,  however, 
traction  is  necessary,  it  should  be  made  at  the  time  of  a  uterine 
contraction  and  assisted  by  pressure  upon  the  fundus.  The  rules 
governing  the  delivery  and  the  treatment  of  complications  have 
already  been  referred  to  under  the  care  of  breech  presentations. 
The  question  as  to  which  hand  to  use  internally  is  decided  "by 
observing  that  when  placed  between  pronation  and  supination  it 
corresponds  with  the  anterior  plane  of  the  foetus." 

The  Forceps. 

What  are  the  powers  of  the  forceps  ? 

1.  A  Dynamic  Action. — Uterine  contractions  are  sometimes  in- 
creased after  the  introduction  of  a  single  blade  of  the  forceps. 
This  result,  however,  is  far  from  being  constant. 

2.  As  Compressors. — The  forceps  should  never  be  used  as  com- 
pressors. The  compression  should  be  sufficient  only  to  prevent 
the  instrument  from  slipping.  The  compression  of  a  diameter 
over  one-third  of  an  inch  is  liable  to  produce  fractures. 

3.  As  Leveies. — A  "  to-and-fro  movement  "  should  be  associated 
with  traction.  Lusk  holds  that  the  "  side-to-side  swaying  of  the 
forcep-handles  "  is  injurious  to  the  maternal  tissues. 

4.  As  Rotators. — The  use  of  the  forceps  as  rotators  is  not,  as  a 
rule,  advised. 

5.  As  Tractors. — This  is  the  chief  and  essential  power  of  the 
forceps.     Traction  should  be  intermittent  and  slow;   imitating 


OBSTETRIC    OPERATIONS 


199 


Nature  as  closely  as  possible.  The  force  exerted  should  not  ex- 
ceed 132  pounds,  and  the  pulling  should  be  done  by  the  fore- 
arms. The  direction  of  the  traction  should  correspond  with  the 
axis  of  the  parturient  canal.  The  axis  of  the  birth-canal  has 
already  been  described,  and,  therefore,  requires  no  further  reference. 
To  effect  axis-traction  two  methods  have  been  described.  One 
known  as  Smith's,  the  other  as  Pajot's.  In  the  former,  the 
operator  grasps  the  handles  of  the  forceps  at  the  end,  while  the 

Fig.  10. 


Traction  with  Tarnier's  forceps. 


dther  hand  makes  downward  pressure  beyond  the  lock.  In  the 
latter,  "we  apply  the  left  hand  as  near  as  possible  to  the  vulva, 
the  right  hand  near  the  end  of  the  handles  ;  then  we  use  sometimes 
these  two  hands  in  order  to  make  the  forceps,  at  times  a  lever  of 
the  first  order,  sometimes  of  the  third,  sometimes  a  lever  and  a 
tractor  at  the  same  time,  sometimes  a  direct  tractor,  according  to 
the  resistance  and  the  height  of  the  pelvis  at  which  they  are 
found."  The  best  method,  however,  of  securing  axis-traction  is 
by  the  use  of  Tarnier's  axis-traction  forceps,  or  by  a  modification 
of  the  instrument  devised  either  by  Lusk  or  Simpson. 


200  ESSENTIALS     OF    OBSTETKICS. 

What  are  the  indications  for  the  use  of  the  forceps  ? 

1.  Whenever  the  life  of  the  mother  or  child,  or  both,  call  for 
immediate  delivery. 

2.  Whenever  the  ordinary  forces  of  labor  are  unable  to  effect 
delivery. 

What  are  the  conditions  necessary  for   the  use   of  the 
forceps  ? 

1.  The  membranes  must  have  ruptured. 

2.  The  cervix  must  be  dilated  or  dilatable. 

3.  The  foetal  head  must  be  normal  in  size  and  consistence. 

4.  The  forceps  is  applied  only  to  the  head  of  the  child.  Occa- 
sionally, however,  to  the  breech  in  pelvic  presentations. 

6.  The  parturient  canal  must  be  large  enough  to  allow  the  child 
to  pass  through  it. 

6.  The  head  must  be  at  the  superior  strait.  The  head  is  spoken 
of  as  being  at  the  superior  strait  when  the  parietal  protuberances 
are  in  relation  with  the  ilio-pectineal  line. 

How  many  acts  are  included  in  the  operation  of  applying 
the  forceps  'i 
Three;  viz.:  1.  Introduction;  2.  Locking;  3.  Extraction. 

What  are  the   rules    governing  the   introduction  of  the 
blades  ? 

1.  Apply  the  blades  to  the  sides  of  the  head. 

2.  "  The  left  blade  is  always  held  in  the  left  hand,  and  is  always 
applied  to  the  left  side  of  the  pelvis ;  the  right  blade  is  always  held 
in  the  right  hand,  and  is  always  applied  to  the  right  side  of  the 
pelvis." 

3.  No  force  should  be  used  in  the  introduction  of  the  blades. 

4.  "  The  second  blade  should  always  be  introduced  above  the 
first." 

5.  The  hand  which  is  to  guide  the  blade  should  always  be  intro- 
duced first. 

6.  In  direct  applications  always  introduce  the  left  blade  first; 
in  oblique,  apply  that  blade  first  which  corresponds  in  name  to  the 
empty  oblique  diameter.  For  example,  in  a  right  occipito-anterior 
position,  the  right  oblique  is  the  empty  diameter,  therefore  apply 


OBSTETKIC    OPERATIONS.  201 

first  the  right  blade  ;  or,  again,  in  a  left  occipito-anterior  position, 
the  left  oblique  is  the  empty  diameter,  therefore  the  left  blade 
is  to  be  applied  first. 

What  are  the  rules  and  precautions  governing  the  locking 
of  the  blades  ? 

1.  No  force  should  be  used  to  lock  the  blades. 

2.  In  oblique  applications  where  the  right-hand  blade  has  been 
introduced  first  and  is  below  the  left,  the  blades  must  be  crossed. 

3.  If  the  handles  are  not  in  the  same  plane  and  locking  cannot 
be  effected,  then  rotate  them  inversely ;  or,  withdraw  the  second 
blade  and  again  introduce  it ;  if  this  fails,  then  reintroduce  both 
blades. 

4.  If  locking  is  prevented  by  one  blade  being  inserted  further 
than  the  other,  withdraw  one  blade  somewhat,  or  push  the  other  in. 

5.  The  handles  may  not  approximate,  due  to  the  head  being 
improperly  seized,  or  to  the  blades  not  being  introduced  far  enough 
over  the  head,  or  to  the  head  being  of  unusual  size. 

6.  In  locking,  care  should  be  taken  to  guard  against  including 
the  hair  or  skin  of  the  external  organs  of  generation. 

7.  The  indications  that  the  forceps  is  properly  applied  are :  it 
locks  easily,  it  gives  a  sensation  of  firmness  when  a  tentative  pull 
is  made,  and  an  examination  with  the  fingers  shows  that  nothing 
has  been  included  in  its  grasp  but  the  head. 

Describe  how  the  extraction  is  accomplished. 

The  handles  should  be  grasped  with  the  right  hand,  with  the 
palm  turned  downward.  If  the  handles  be  provided  with  trans- 
verse shoulders,  the  index-finger  is  placed  over  one  shoulder,  while 
the  middle  finger  grasps  the  other.  The  left  hand  should  grasp 
the  handles  beyond  the  position  of  the  right,  with  the  index-finger 
extended  and  in  contact  with  the  child's  head.  Or  the  left  hand 
may  grasp  the  handles  from  below,  with  the  palm  turned  upward. 
Traction  should  not  be  continued  longer  than  from  one  to  two 
minutes  at  a  time.  There  should,  as  a  rule,  be  no  haste  in  effect- 
ing delivery.  If  uterine  contractions  are  present,  traction  should 
be  made  during  a  pain.  If  the  head  be  high  up,  traction  should 
be  made  downward  and  backward  until  the  head  is  below  the 
symphysis  pubis ;  then  the  pull  becomes  horizontal  in  direction ; 


202  ESSENTIALS    OF    OBSTETEICS. 

when  the  occiput  has  reached  the  vulva  the  forceps  is  directed  up 
toward  the  mother's  abdomen.  When  the  occiput  comes  under 
the  symphysis  pubis,  traction  with  the  forceps  is  no  longer  indi- 
cated. Our  object  now  is  to  hold  the  head  firmly,  and  prevent  its 
too  rapid  delivery.  Not  only  must  the  perineum  be  supported, 
but  it  must  be  given  time  to  relax,  which  can  only  be  accom- 
plished by  keeping  back  the  head.  Delivery  of  the  head  should 
be  completed  in  the  interval  of  a  pain.  The  forceps  is  not  to  be 
removed  until  the  head  is  born.  Lusk,  however,  with  Goodell  and 
others,  teaches  that  the  forceps  is  to  be  removed  as  soon  as  the  occi- 
put is  well  under  the  pubes,  and  the  perineum  begins  to  distend. 

What  should  be  the  position  of  the  patient  during  the 
operation  ? 

If  the  head  be  in  the  cavit}',  or  at  the  superior  strait,  place  the 
patient  across  the  bed,  with  her  buttocks  over  the  edge,  her  feet 
placed  upon  chairs,  and  her  knees  supported  on  each  side  by  an 
assistant.  If,  on  the  other  hand,  the  head  is  near  the  vulva,  bring 
her  to  the  foot  of  the  bed,  and  flex  the  lower  limbs. 

Should  an  anaesthetic  be  administered  ? 

Yes,  as  a  rule.  The  anaesthesia,  however,  should  be  obstetric, 
not  surgical. 

What  preparations  should  be  made  for  using  the  forceps  ? 

The  bladder  and  rectum  should  be  emptied.  The  following 
articles  should  be  at  hand,  viz. :  hot  and  cold  water,  a  fountain 
syringe,  a  hypodermatic  syringe,  sulphuric  ether,  the  fluid  extract 
of  ergot,  and  a  solution  of  corrosive  sublimate,  1  part  to  3000. 

Is  it  important  to  make  a  positive  diagnosis  of  the  presen- 
tation and  position  of  the  foetus  before  introducing 
the  forceps  ? 

Yes.  It  is  impossible  to  apply  the  blades  or  to  deliver  unless  the 
presentation  and  position  are  known.  If  the  operator  is  uncertain 
in  his  diagnosis,  he  should  introduce  the  hand  into  the  vagina 
before  applying  the  forceps. 

Describe  the  application  of  the  forceps  in  head-first  labor. 

In  delivering  with  the  forceps  it  is  absolutely  necessary  to  remem- 
ber and  to  assist  the  normal  mechanism  of  labor. 


OBSTETRIC    OPERATIONS.  203 

1.  Occipito-pubic  Position.— The  blades  of  the  forceps  are  applied 
to  the  sides  of  the  child's  head,  and  are  parallel  with  the  sides  of 
the  mother's  pelvis.  The  left-hand  blade  is  introduced  first.  Trac- 
tion is  made  downward  until  the  occiput  comes  in  front  of  the 
pubes,  when  the  handles  are  gradually  elevated  toward  the  mother's 
abdomen,  so  as  to  assist  extension. 

2.  Occipito-sacral  Position.— The  position  of  the  blades  and  their 
introduction  are  the  same  as  in  an  occipito-pubic  position.  The 
direction  of  the  pull  must  be  upward  and  forward,  until  the  occiput 
is  born  over  the  anterior  edge  of  the  perineum,  when  the  head 
becomes  extended. 

3.  Left  Occipito- anterior  Position.— Introdnce  the  left  blade  first. 
Eotation  should  not  be  attempted  until  the  head  occupies  the 
pelvic  floor.  After  rotation  takes  place  delivery  follows,  as  in  an 
occipito-pubic  position. 

4.  Eight  Occipito-posterior  Position. — The  introduction  and  posi- 
tion of  the  blades  are  the  same  as  in  a  left  occipito-anterior  position. 
After  the  head  reaches  the  floor  of  the  pelvis,  an  attempt  should 
be  made  to  bring  about  anterior  rotation.  If  this  is  successful, 
remove  the  blades  and  then  reapply  them.  If,  however,  posterior 
rotation  occurs,  deliver  as  in  an  occipito-posterior  position. 

5.  Left  Occipito-posterior  Position. — Introduce  the  right  blade  first. 
After  the  introduction  of  the  blades  the  right  will  be  below  the 
left;  to  lock  them  cross  the  handles  and  bring  the  right  blade 
above.  Stolz  raises  the  handle  of  the  right  blade  and  introduces 
the  left  beneath  it,  thus  placing  the  blades  in  their  proper  posi- 
tion. The  delivery  is  accomplished  as  in  a  right  occipito-posterior 
position. 

6.  Bight  Occipito-anterior  Position. — The  introduction  of  the  blades 
is  the  same  as  in  a  left  occipito-anterior  position ;  the  delivery  is 
accomplished  as  in  a  left  occipito  anterior  position. 

Describe  the  application  of  the  forceps  in  head-last  labor. 

1.  Eotation  of  the  Face  Posteriorly. — This  is  the  normal  rotation 
in  a  breech  presentation.  Raise  the  body  of  the  child  upward,  its 
back  directed  toward  the  mother's  abdomen.  Apply  the  forceps 
to  the  sides  of  the  head ;  the  left  blade  first.  The  nucha  pivots  on 
the  subpubic  ligament  and  the  head  is  born  by  flexion. 


204  ESSENTIALS    OF    OBSTETKICS. 

2.  Rotation  of  the  Occiput  Posteriorly. 

a.  Head  flexed.    Carry  the  back  of  the  child  backward  toward 

the  mother's  back ;  apply  the  blades  to  the  sides  of  the 
head ;  the  left  blade  first.  The  head  is  born  by  the  nucha 
pivoting  upon  the  anterior  margin  of  the  perineum. 

b.  Head  extended.     Hold  the  body  of  the  child  in  a  vertical 

position,  its  anterior  plane  being  directed  toward  the 
mother's  abdomen.  Introduce  the  blades  to  the  sides  of 
the  head ;  the  left  blade  first. 

Describe  the  application   of  the  forceps  with  the   head 
movable  above  the  inlet. 

The  head  is  held  in  position  by  an  assistant  making  pressure 
upon  the  lower  part  of  the  abdomen  of  the  mother.  It  is  almost 
impossible  to  apply  the  blades  to  the  sides  of  the  child's  head. 
As  a  rule,  they  assume  an  oblique  position  with  reference  to  the 
head.  Thus,  the  left  blade  is  placed  over  the  right  side  of  the 
frontal  bone,  while  the  right  blade  passes  over  the  occipital  bone 
on  the  left  side.  If,  after  a  fair  trial,  the  head  cannot  be  made  to 
descend  into  the  inlet,  the  forceps  must  be  abandoned,  and  some 
other  method  of  delivery  instituted. 

Describe  the  application  of  the  forceps  when  the  head  has 
become  separated  from  the  body. 
Fix  the  head  by  pressure  upon  the  mother's  abdomen,  and  apply 
the  blades  to  the  sides  of  the  child's  head ;  or  fix  the  head  by 
introducing  the  hand  into  the  uterus. 

Describe  the  application  of  the  forceps  in  face  presenta- 
tions. 
If  the  chin  rotates  posteriorly,  the  application  of  the  forceps  is 
unjustifiable.  Delivery  cannot  be  accomplished  unless  the  chin 
rotates  anteriorly.  If  the  head  be  above  the  pelvic  inlet,  the 
application  of  the  forceps  is  both  dangerous  and  difficult :  there- 
fore, the  presentation  should  be  converted  into  a  vertex,  or  podalic 
version  performed.  If,  however,  the  head  be  at  the  superior  strait, 
or  in  the  pelvic  cavity,  the  application  of  the  forceps  follows  the 
same  rules  as  in  other  presentations.  The  application  of  the  blades 
should  always  be  upon  the  aides  of  the    head.      In  transverse 


OBSTETKIC    OPERATIONS.  205 

positions,  however,  this  cannot  be  accomplished  ;  under  these  cir- 
cumstances, "  one  blade  is  placed  upon  the  cheek  and  the  base  of 
the  jaw,  while  the  other  is  upon  the  temporo-occipital  region  of 
the  opposite  side." 

Describe  the  application  of  the  forceps  to  the  breech. 

1.  Child  Dead. — Apply  the  forceps  to  the  sides  of  the  pelvis, 
and  make  firm  compression  and  deliver. 

2.  Child  Living. — Great  care  should  betaken  to  prevent  injury 
to  the  bones  of  the  pelvis.  Tarnier's  axis-traction  forceps  is  the 
best  instrument  to  use.  The  breech  is  seized  by  the  sacro-pubic 
diameter  or  by  the  bistrochanteric.  The  delivery  must  be  gradual, 
and  without  force. 

Embryotomy. 

What  is  embryotomy  ? 

The  operation  "  employed  to  lessen  the  size  of  the  foetus,  facili- 
tating or  rendering  possible  its  transmission  through  the  birth- 
canal."  (Parvin.) 

What   operations   are   included  under   the   term   embry- 
otomy ? 

1.  Craniotomy;  2.  Cephalotripsy ;  3.  Cranioclasty ;  4.  Lami- 
nation ;  5.  Decollation ;  6.  Evisceration ;  7.  Spondylotomy. 

What  are  the  indications  for  the  performance  of   embry- 
otomy ? 

The  operation  is  indicated  when  there  exists  a  disproportion 
between  the  foetus  and  the  parturient  canal. 

1.  Foetus. 

a.  Extraordinarily  developed  children. 

b.  Premature  ossification  of  the  cranial  bones. 

c.  Increased  size  due  to  pathological  causes,  as,  for  example, 

hydrocephalus. 

d.  Monstrosities. 

e.  Neglected  shoulder  presentations. 

/.  Anomalies  in  the  mechanism  of  labor,  as,  for  example  a 
posterior  rotation  of  the  chin,  in  a  face  presentation. 

2.  Mother. 

a.  Pelvic  deformity. 

b.  Neoplasms  and  cicatrices. 


206  ESSENTIALS     OF    OBSTETKICS. 

Narrowing  of  the  birth-canal  as  an  indication  for  the  perform- 
ance of  embryotomy  will  be  considered  in  full  in  the  chapter  on 
Ccesarean  Section. 

In  what  presentations  may  craniotomy  be  performed? 

In  a  presentation  of  the  vertex  or  of  the  face,  or  the  after-coming 
head. 

Describe  the  method  of  operating^  in  craniotomy. 

1.  Vertex  Presentations. — Place  the  patient  in  the  position  already 
described  for  the  application  of  the  forceps.  The  bladder  and 
rectum  should  be  emptied ;  ansesthesia  is,  as  a  rule,  unnecessary. 
The  best  instrument  for  perforation  is  Smellie's  scissors,  or  one  of 
its  modifications.  If  an  attempt  has  been  made  to  deliver  with 
the  forceps  prior  to  perforation,  it  is  well  to  allow  it  to  remain 
applied  to  the  head  and  perforate  between  the  blades.  If,  how- 
ever, the  forceps  has  not  been  introducedj  the  foetal  head  is  ren- 
dered immovable  by  pressure  upon  it  through  the  abdominal  wall. 
Two  fingers  of  the  left  hand  are  introduced  into  the  vagina,  and 
their  tips  brought  into  contact  with  the  foetal  head ;  the  perforator, 
held  in  the  right  hand,  is  guided  by  the  fingers  in  the  vagina 
until  its  point  comes  against  the  cranium  of  the  foetus.  The  point 
of  the  instrument  is  now  pressed  against  the  skull  and  rotated 
from  right  to  left,  and  from  left  to  right,  until  it  perforates  the 
bone.  After  the  instrument  has  entered  the  brain  cavity  the 
blades  are  separated  and  the  opening  enlarged.  The  instrument 
is  now  thrust  deep  down  into  the  brain  substance  and  moved 
about  in  every  direction,  so  as  to  destroy  completely  the  structures 
at  the  base  of  the  brain.  It  is  better  not  to  perforate  the  skull 
through  a  suture  or  fontanelle,  as  the  opening  is  more  liable  to 
remain  patulous  if  made  directly  through  the  bone.  As  a  rule,  it  is 
unnecessary  to  evacuate  completely  the  brain  substance ;  if,  how- 
ever, it  be  thought  best  to  do  so,  a  warm  solution  of  corrosive  sub- 
limate, 1  part  to  4000,  thrown  in  from  the  nozzle  of  a  syringe,  will 
entirely  empty  the  cranial  cavity.  The  delivery  of  the  foetus  may 
now  be  accomplished  with  the  crotchet,  or,  better  still,  with  a 
cranioclast,  or  a  cephalotribe. 

2.  Face  Presentations. — Perforation  is  best  done  through  the 
frontal  bone.    The  instrument  may  be  made  to  enter  the  brain 


OBSTETRIC    OPERATIONS.  207 

either  through  the  orbit  or  the  palatine  arch ;  the  last  situation  is 
the  most  difficult. 

3.  TJie  After-coming  Head. — The  body  of  the  child  is  held  out 
of  the  way  by  an  assistant,  and  the  perforator  made  to  enter  the 
cranium  through  one  of  the  posterior  lateral  fontanelles.  Perfo- 
ration may  also  be  accomplished  either  under  the  chin  or  through 
the  palatine  vault.  The  extraction  of  the  head  is  accomplished 
with  the  cephalotribe. 

What  is  cephalotripsy  ? 

An  operation  by  which  the  foetal  head  is  crushed,  in  order  to 
diminish  both  its  size  and  resistance. 

Describe  the  method  of  operating  in  cephalotripsy. 

The  patient  should  be  anaesthetized  and  placed  in  the  position 
advised  for  the  application  of  the  forceps.  The  blades  of  the 
cephalotribe  are  introduced  along  the  sides  of  the  head.  The 
general  rules  for  the  application  of  the  instrument  are  the  same  as 
those  given  for  the  forceps.  Perforation  should  always  be  performed 
before  the  cephalotribe  is  applied.  The  crushing  of  the  foetal 
head  should  be  slow  and  intermittent.  Later,  however,  the  process 
must  be  more  rapid,  or  the  instrument  will  slip  when  traction  is 
made.  In  making  traction  the  instrument  should  be  grasped  in 
both  hands.  A  quarter  rotation  of  the  cephalotribe  is  now  made, 
which  brings  the  crushed  diameter  of  the  foetal  head  into  the 
antero-posterior  diameter.  Traction,  associated  with  a  side-to-side 
movement,  is  then  made,  as  in  extraction  with  the  forceps.  It  is 
of  first  importance  to  remember,  in  the  application  of  the  blades  of 
the  instrument,  to  introduce  them  well  over  the  base  of  the  skull. 

Describe  the  method  of  operating  in  cranioclasty. 

The  eranioclast  consists  of  two  blades,  one  of  which  is  fenes- 
trated, and  smooth,  while  the  other  is  roughened  and  fits  into  the 
first. 

Perforation  of  the  skull  should  always  be  performed  before  the 
cranioclast  is  applied.  The  solid  blade  is  introduced  within  the 
cranial  cavity,  and  the  fenestrated  blade  is  applied  without.  When 
locked  the  former  blade  fits  into  the  concavity  of  the  latter.    After 


208  ESSENTIALS    OF    OBSTETRICS. 

crushing  the  bones,  the  instrument  may  either  be  withdrawn,  and 
the  case  left  to  Nature,  or  the  head  may  be  delivered  by  traction. 

What  is  meant  by  lamination  ? 

An  operation  by  which  the  foetal  head  is  divided  into  several 
segments. 

What  is  meant  by  decollation  or  decapitation  ? 

An  operation  by  which  the  foetal  head  is  separated  from  the 
trunk. 

What  is  the  indication  for  this  operation  ? 

In  a  shoulder  presentation  when  version  is  impracticable,  either 
on  account  of  a  threatened  rupture  of  the  uterus  or  of  the  present- 
ing part  becoming  impacted. 

How  is  the  operation  performed  ? 

Prof.  Parvin  recommends  that  a  piece  of  stout  twine  be  intro- 
duced through  the  eye  of  a  blunt  hook  and  carried  around  the 
neck  of  the  foetus.  Each  end  of  the  twine  is  now  tied  to  a  piece 
of  wood,  and  crossed.  The  neck  is  then  divided  by  a  saw-like 
movement  given  to  the  string.  Dubois  recommends  making  trac- 
tion on  the  prolapsed  arm,  and  then  carrying  a  blunt  hook  over 
the  neck.  He  then  with  a  pair  of  blunt-pointed  scissors  separates 
the  head  from  the  trunk.  Another  excellent  plan  is  cutting  the 
neck  with  an  ecraseur. 

What  is  spondylotomy  ? 

An  operation  by  which  the  spinal  column  is  divided  at  any  part 
except  the  neck.  The  operation  may  be  performed  with  the  scis- 
sors of  Dubois. 

What  is  evisceration  ? 

The  removal  of  the  viscera  from  the  thoracic  or  abdominal 
cavity. 

When  is  the  operation  indicated  ? 

In  a  shoulder  presentation  where  decollation  is  difficult  or  im- 
possible, or  in  certain  cases  of  great  pelvic  narrowing. 

How  is  the  operation  performed  ? 

With  the  scissors  of  Dubois  or  an  ordinary  perforator.     In  re- 


OBSTETBIC    OPERATIONS.  209 

moving  the  viscera  the  volsella  forceps  may  be  used  to  aid  the 
fingers.  After  the  contents  are  removed  podalic  version  may  be 
performed,  or  the  bluut  hook  or  the  crotchet  employed  to  effect 
delivery.  If  an  arm  is  prolapsed,  it  may  be  seized  and  traction 
made,  delivery  being  effected  as  jn  spontaneous  evolution  of  the 
shoulder. 

What  are  the  advantages  of  Tarnier's  basiotribe  ? 

It  is  a  perforator  and  a  cranioclast  combined.  It  also  breaks 
the  base  of  the  head  by  crushing,  not  by  penetrating  it,  as  some  of 
the  other  instruments  do. 


The  Caesarean  Section. 

What  is  the  Caesarean  section  ? 

An  operation  which  consists  in  making  an  incision  into  the  ab- 
domen and  the  uterus,  in  order  thus  artificially  to  deliver  the 
foetus. 

What  term  is  used  as  a  synonym  for  the  Caesarean  section? 

Gastro-hysterotomy. 

What  is  meant  by  the  "  improved  Caesarean  section,"  or 
*'  Sanger's  operation  ?  " 
The  operation  of  gastro-hysterotomy  as  now  performed.      As 
Sanger  is  entitled  to  much  of  the  credit  in  the  technique  of  the 
operation,  his  name  has  become  associated  with  it. 

What  are  the  indications  for  gastro-hysterotomy  ? 

1.  Pelvic  deformity ;  2.  Neoplasms  encroaching  upon  the  birth- 
canal  ;  3.  Carcinoma  of  the  cervix,  in  an  advanced  stage ;  4.  Pos- 
sibly also,  for  excessive  size  and  mal-presentations  of  the  foetus,  in 
cases  where  embryotomy  would  be  indicated ;  5.  In  certain  ano- 
malies of  the  soft  parts  due  either  to  an  arrest  of  development 
or  to  acquired  malformations. 

How  are  the  indications  divided? 

1.  Absolute.— \Y\ien  the  foetus  cannot  be  extracted  through  the 
natural  passage,  living  or  dead. 

14 


210  ESSENTIALS    OF    OBSTETRICS. 

2,  Relative. — When  we  have  to  choose  between  embryotomy  and 
gastro- hysterotomy; — i.e.,  in  cases  where  it  is  possible  to  deliver 
by  the  former  operation. 

When  are  the  indications  for  gastro-hysterotomy  absolute  ? 

In  all  cases  where  the  antero -posterior  diameter  of  the  superior 
strait  is  below  two  inches;  possibly  it  would  be  better  to  place  the 
limit  at  two  and  a  half  inches.  Carcinoma  of  the  cervix  in  an 
advanced  stage,  and  in  certain  anomalies  of  the  soft  parts,  due  to 
an  arrest  of  development,  or  to  acquired  malformations. 

When  are  the  indications  for  the  operation  relative  ? 

When  the  antero-posterior  diameter  of  the  inlet  is  between  two 
and  three  inches.  Also  in  excessive  size  and  mal-presentations  of 
the  foetus.  The  latter  indication,  however,  is  not  accepted  by  all 
authorities. 

What  is  the  best  time  to  perform  the  operation  ? 

After  the  labor  has  been  in  progress  for  five  or  six  hours,  and 
before  the  membranes  have  ruptured.  Under  these  circumstances 
the  OS  uteri  is  more  or  less  dilated  and  offers  better  drainage ;  the 
uterine  contractions  are  stronger;  and  the  liquor  amnii  distending 
the  uterus  assists  materially  when  the  incision  is  made  through 
that  organ. 

Describe  the  operation  of  gastro-hysterotomy. 

1.  Preliminary  Preparations. — The  abdomen  should  be  rendered 
aseptic  in  a  manner  similar  to  that  employed  in  all  abdominal 
sections.  The  external  organs,  the  vagina,  and  the  cervix  must 
be  thoroughly  cleansed  with  a  solution  of  corrosive  sublimate, 
1  to  2000.  The  instruments,  sponges,  and  ligatures,  and  the  hands 
and  forearms  of  the  operator  and  his  assistants  must  be  prepared 
with  the  usual  antiseptic  precautions.  The  rectum  and  bladder 
must  be  emptied,  and  the  patient  anaesthetized. 

2.  Incisions  through  the  Abdomen. — The  incision  should  be  made 
in  the  median  line,  about  6.3  inches  long,  in  a  line  corresponding 
with  the  middle  third  of  the  uterus.  This  incision  should  be 
made  in  precisely  the  same  manner  as  in  ovariotomy. 

3.  Incision  through  the  Uterus.  —  The  incision  is  made  in  the 


OBSTETKIC    OPERATIONS. 


211 


middle  third  of  the  median  line.     If  the  placenta  is  in  the  line  of 
the  incision,  cut  rapidly  through  it,  or  detach  one  side. 

4.  Delivery  of  Child  and  Eventration  of  the  Uterus. — Grasp  the 
child  by  the  feet  and  withdraw  it,  at  the  same  time  eventrate  the 
uterus.  While  this  is  being  done  an  assistant  keeps  the  abdominal 
walls  closely  in  contact  with  the  uterus.  After  eventration  of  the 
uterus  has  been  effected,  a  large  flat  sponge,  or  towel,  is  placed 
behind  it  to  protect  the  bowels. 

Fig.  11. 


The  deep  and  superficial  uterine  sutures.     (Zinke.) 


5.  Hemorrhages.  —  Hemorrhages  may  be  controlled  by.  encircl- 
ing the  neck  of  the  uterus  with  a  rubber  tube,  or  by  an  assistant 
making  compression  with  his  hands,  or  by  twisting  the  organ  in 
its  longitudinal  axis. 

6.  Delivery  of  Placenta. — The  placenta  is  now  detached  from  its 
attachments  with  the  fingers,  and  removed  from  the  uterus. 

7.  Suturing  the  Uterus. — Before  closing  the  opening  into  the 
uterus  see  that  the  internal  os  is  patulous  and,  if  necessary,  wash 
out  the  cavity  with  a  corrosive  sublimate  solution,  1  to  4000,  and 


212  ESSENTIALS    OF    OBSTETRICS. 

apply  iodoform.  The  uterine  opening  is  closed  by  two  sets  of 
sutures;  deep  and  superficial  (Fig.  11),  the  deep  sutures  being 
of  silver  wire,  and  the  superficial  of  silk.  The  former,  eight  to  ten 
in  number,  are  introduced  about  1  cm.  from  the  edge  of  the  inci- 
sion and  penetrate  through  the  peritoneal  and  muscular  coat,  down 
to,  but  not  through,  the  decidua ;  they  are  then  brought  out  at  the 
same  distance  on  the  opposite  side  of  the  wound.  These  sutures 
are  then  secured  by  twisting.  The  superficial  sutures  are  of  silk ; 
a  large  number  must  be  used,  twenty  to  twenty-five.  Lembert's 
method  of  introducing  these  sutures  is  employed  (Fig.  11). 

8.  Removal  of  the  Rubber  Tube. — The  rubber  tube  is  now  removed 
from  around  the  neck  of  the  uterus ;  if  bleeding  occurs,  additional 
sutures  should  be  introduced  along  the  line  of  incision. 

9.  Return  of  the  Uterus  into  the  Abdominal  Cavity. — The  uterus 
should  now  be  cleansed  with  an  antiseptic  solution,  iodoform 
applied  along  the  line  of  incision,  and  returned  to  the  abdominal 
cavity. 

10.  Toilette  of  the  Abdominal  Cavity. — If  fluids  have  gained  access 
to  the  cavity  of  the  abdomen,  it  should  be  thoroughly  irrigated 
with  hot  distilled  water,  which  has  been  previously  boiled. 

11.  Suturing  the  Abdominal  Incision. — The  abdominal  wound  is 
closed  and  the  dressings  applied,  in  a  manner  similar  to  that  em- 
ployed in  all  abdominal  sections. 

12.  After-treatment.  —  Several  hypodermatic  injections  of  ergot 
should  be  given.  Vaginal  injections  are  not  indicated  unless  the 
pulse  and  temperature  become  abnormal.  The  general  treatment 
is  the  same  as  in  ovariotomy. 

The  Post-mortem  Osesarean  Section. 

What  conclusions  have  been  drawn  on  this  subject? 

The  following  are  the  conclusions  of  Breslau,  quoted  by  Char- 
pentier. 

1.  "  There  can  be  no  doubt  that  the  foetus,  human  as  well  as 
animal,  survives  the  mother  when  death  has  been  sudden,  as  in 
hemorrhage,  asphyxia,  apoplexy,  etc." 

2.  *'  The  human  foetus  survives  the  sudden  maternal  death  longer 
than  the  animal  foetus." 


OBSTETRIC    OPERATIONS.  2J.3 

3.  "  The  section  is  not  likely  to  save  the  child  if  performed 
beyond  fifteen  or  twenty  minutes  after  the  maternal  death.'' 

4.  "  If  the  mother  dies  of  an  essential  fever,  we  cannot  hope  to 
save  the  infant,  because  its  life-supplies  have  not  been  cut  off  sud- 
denly, but  little  by  little." 

Under  what  circumstances  should  the  post-mortem  Caesa- 
rean  section  be  performed? 

As  soon  as  the  death  of  the  mother  is  established,  unless  it  can 
be  extracted  more  readily  through  the  birth-canal. 

Post-mortem  Extraction  through  the  Natural  Passages. 

What  rules  should  guide  us  in  performing  this  operation  ? 

1.  "Labor  has  commenced,  cervix  is  dilated,  or  dilatable;  rapid 
extraction  by  forceps,  or  by  version." 

2.  "  Labor  has  not  begun. 

a.  "The  woman  is  dead,  or  in  a  state  of  apparent  death  ;  de- 
livery per  vias  naturales,  by  incision  of  cervix,  if  neces- 
sary, and  forceps  or  version. 

h.  "The  woman  is  in  extremis:  Respect  her  condition  and  do 
not  hasten  her  end  by  manoeuvres  which  may  possibly 
not  save  the  child.  Once  the  mother  is  dead,  however, 
act  quickly  in  the  interests  of  the  child."  (Charpentier.) 


INDEX. 


ABDOMIISTAL   muscles,   action   of, 
in  labor,  111 
plates,  30 
pregnancy,  94 
touch,  61 
Abortion,  85 

after-treatment  of,  92 

antisepsis  in,  92 

beginning,  recognition  of,  88 

causes  of,  86 

characteristic  symptoms  of,  88 

immediate  dangers  of,  88 

incomplete,  85 

treatment  of,  90 
induction  of,  indication  for,  190 
methods  of,  191 
prognosis  of,  191 
inevitable,  conditions  of,  88 
missed,  86 

indications  in  treatment  of, 
92 
premonitory  symptoms  of,  87 
period  of  occurrence  of,  86 
recurrence  of,  87 
tampon  in,  90 
threatened,  treatment  of,  89 
treatment  of,  prophylactic,  89 
Accidental  hemorrhage,  101 
Acephalic  monsters,  162 
Allantois,  31 
Amnion,  31 

Anaesthesia  in  breech   presentation, 
147 
in  labor,  134 

indications  for,  134 
Anencephalic  monsters,  160 
Anteversion  of  uterus,  treatment  of, 

79 
Antisepsis,  150 
Area  germinativa,  30 
opaca,  30 
pellucida,  30 
Arm,  dorsal  displacement  of,  156 
Artificial  respiration,  144 


Asphyxia  livida,  symptoms  of,  143 

treatment  of,  144 
pallida,  symptoms  of,  143 

treatment  of,  143 
Auscultation  in  pregnancy,  63 

signs,  determined  by,  63 


BAG  of  waters.  111 
rupture  of.  111 

Basiotribe,  Tarnier's,  209 

Bladder,  attention  to,  in  labor,  154 

Blastodermic  vesicle,  30 

Blastopore,  30 

Braxton  Hicks's  sign  of  pregnancy, 
62 

Breech,  positions  of,  126 

Broad  ligaments,  changes  in,  in  preg- 
nancy, 58 


CESAREAN  section,  209 
post-mortem,  212 

necessity  for,  213 
Capuron,  cardinal  points  of,  IS 
Caput  succedaneum,  114 
Cardiac  souffle,  64 
Catheter,  introduction  of,  29 
Cavity  of  pelvis,  axis  of,  24 
Cephalotripsy,  method  of  operating 

in,  207 
Certain  signs  of  pregnancy,  64 
Cervix,  changes  of,  in  pregnancy,  58 
dilatation  of,  in  labor,  110 
treatment  of  rigidity  of,  153 
Changes    in   maternal  organism   in 

pregnancy,  55 
Characteristic  synaptoms  of  abortion, 

88 
Chloral,  use  of,  in  labor,  135 
Chorion,  32 

Cicatrices  of  pregnancy,  55 
Ciliae  of  uterus,  28 
of  oviducts,  28 

-        (215) 


216 


INDEX. 


Circulation,  foetal,  40 

intra-uterine,  40 

placental,  40 
Clitoris,  34 
Cloaca,  34 
Conception,  53 
Confinement,  date  of,  68 
Contractility  of  uterus,  57 
Cord,  coils  of,  140 

ligation  of,  141 

prolapse  of,  causes  of,  166 
diagnosis  of,  167 
prognosis  of,  167 
reposition  of,  168 
treatment  of,  167 
Corpus  luteum,  48 
Cranioclasty,  207 
Craniotomy,  206 
Cranium,  43 

Cyclocephalic  monsters,  161 
Cyst,     symptoms    of     rupture     of. 


DECAPITATION,  208 
Deciduous  membranes,  31 
Decollation,  164 
Delivery,  preparation  for,  139 
Diagnosis  of  pregnancy,  67 
Discus  proligerous,  49 
Diseases  of  ovum,  81 
Dorsal  plates,  30 
Doubled  foetus,  management  of  labor 

in,  149 
Dystocia  in  plural  deliveries,  164 

ECLAMPSIA,  102 
etiology  of,  103 
prognosis  of,  104 
treatment  of,  curative,  106 
obstetric,  106 
prophylactic,  105 
Ectopic  development  of  ovum,  92 
Ectromelic  monsters,  159 
Elbow,  diagnosis  of,  124 
Embryo,  development  of,  39 
Embryology,  30 
Embryotomy,  205 
Ensomphalic  monsters,  162 
Epiblast,  30 
Episiotomy,  140 
Eventration  of  uterus,  211 
Evisceration,  208 
Exencephalic  monsters,  16.0 


External    genitalia,  changes    of,   in 

pregnancy,  55 
Extra-uterine  gestation,  95 
Extra-uterine  pregnancy,  92 

FACE,  positions  of,  125 
Fecundation,  54 
Foetal  appendages,  32 

in  twin  pregnancies,  70     - 
head,  circumference  of,  44 
diameters  of,  44 
motions  of,  45 
palpation  of,  118 
heart  sounds,  63 

fi'equency  of,  64 
relation  to  sex  of,  64 
trunk,  diameters  of,  45 
Foetus,  attitude  of,  46 

causes  of  presentation  of,  46 
development  of,  37 
diagnosis  of  death  of,  68 
excessive  development  of,  156 
functions  of,  39 
lie  of,  118 
movements  of,  42 
nourishment  of,  39 
physiology  of,  39 
respiratory  organs  of,  41 
secretory  organs  of,  42 
viability  of,  39 
Foot,  diagnosis  of,  123 
Forceps — 

anaesthesia  in  application  of,  202. 
application  of,  200 

in  breech  presentations,  205 
in  face  presentations,  204 
in  head-first  labors,  202 
in  head-last  labors,  203 
in  head  separated  from  body, 
204 
conditions  necessary  in  use  of,  200 
direction  of  force  in  use  of,  199 
extraction  with,  201 
high  application  of,  204 
indications  for  use  of,  200 
position  of  patient  in  use  of,  202 
powers  of,  198 
precautions  in  locking  blades  of, 

201 
preparation  of,  for  use,  202 
rules  governing  introduction  of, 
200 
locking  of,  201 
Tarnier's  axis-traction,  199 


INDEX, 


217 


GASTEO-HYSTERECTOMY,  after- 
treatment  in,  212 
hemorrhage  in,  211 
indications  for,  209 
operation  described,  210 
preliminary       preparations 

for,  210 
time  for,  210 
Gavage,  146 

Generative  organs,  development  of, 
34 
internal,  35 
Genital  fissure,  34 
folds,  34 
sense,  51 
tubercle,  34 

HAISTD,  differential  diagnosis  of,  127 
Hands,  preparation   of,   before 
labor,  150 
Hegar's  sign  of  pregnancy,  62 
Hemorrhage,  accidental,  101 
symptoms  of,  102 
treatment  of,  102 
after  expulsion  of  placenta,  112 
post-jjartum,  180 

after-treatment  of,  182 
divisions  of,  180 
indications  for  treatment  in, 

181 
primary,  causes  of,  180 
secondary,  causes  of,  182 
treatment  of,  182 
unavoidable,  98 
source  of,  99 
Hydatidiform  mole,  81 
prognosis  of,  83 
symptoms  of,  81 
treatment  of,  83 
Hy  drocephal  us — 

festal  mortality  in,  158 
indications  in  treatment  of,  158 
interference   of,  with  accommo- 
dation, 158 
management  of,  in  labor,  157 
maternal  mortality  in,  158 
Hyperemesis,  72 

division  of  symptoms  of,  72 
duration  of,  73 
period  of  occurrence  of,  72 
prognosis  of,  73 
synn:)toms  of,  73 
treatment  of,  74 
Hypoblast,  30 


TNCARCERATION  of  uterus,  results 
1  of,  80 

symptoms  of,  80 

treatment  of,  81 
Incomplete  abortion,  85 
Indigation,  diagnosis  of  position  by, 
124 
diagnosis  of  presentation  by,  122 
Inlet,  axis  of,  24 
Interstitial  pregnancy,  93 
Irritability  of  uterus,  57 

KIDNEY,  secretion  of,  in  foetus,  42 
Knee,  diagnosis  of,  124 


LABIA  majora,  34 
minora,  34 
Labor — 

arrangement  of  patient  in,  136 
articles  necessary  in,  136 
bladder  and  rectum  in,  137 
classification  of,  107 
delayed  treatment  of,  153    . 
determining  causes  of,  107 
dilatation  of  cervix  in,  137 
division  of  phenomena  of,  109 
duration  of,  113 
effects  of,  upon  mother,  113 

upon  foetus,  113 
efficient  causes  of,  107 
false  pains  of,  113 
indications  of  commencement  of, 

108 
ineffective  pains  in,  154 
levelling  in,  128 
management  of,  134 
first  stage,  136 

bladder  and  rectum,  137 
dilatation  of  cervix,  137 
food  and  drink,  137 
preliminary      prepara- 
tion, 135 
preparation  of  bed,  136 
second  stage,  137 
third  stage,  138 

belly-band,  application 
'       of,  143 
binder,  application  of,142 
care  of  mother  in,  141 
care  of  child  in,  141 
cord,  treatment  of,  142 
placental  delivery,  141 
use  of  ergot  in,  142 


218 


INDEX. 


Labor — 

mechanism  of,  115 

face  presentation,  131 
in  justo-minor  pelvis,  171 
pelvic  presentation,  132 
vertex  presentation,  127 
natural  conditions  necessary  for, 

107 
pains  of  first  stage,  109 

second  stage,  113 
plastic  phenomena  of,  114 
precursory  symptoms  of,  108 
prolonged,  152 

temporary  exhaustion  in,  154 
Lamination,  208 
Leucorrhoea,  treatment  of,  78 
Lymphangitis,  septic,  185 


MAMMARY  glands,  changes  of,  in 
pregnancy,  58 
Mechanical  phenomena  of  labor,  115 
Mechanism  of  labor,  115 
divisions  of,  127 
description  of,  134 
Meconium,  42 
Membrana  reflexa,  31 
scroti  na,  31 
vera,  31 
Menopause,  52 
Menstruation,  49 
■  duration  of,  51 
causes  of,  51 
occurrence  of,  in  lactation,  51 

in  pregnancy,  51 
source  of,  50 
Mesoblast,  30 
Missed  abortion,  86 

labor,  69 
Monocephalic  monsters,  163 
Monomphalic  monsters,  162 
Monosomic  monsters,  163 
Monsters,  double,  162 

parasitic,  164 
Monstrosities,  classification  of,  159 
Mliller's  ducts,  35 
Multiple  pregnancy,  69 

condition  necessary  for,  69 
'  management  of  labor  in,  149 
Muriform  body,  30 


\rUBILITY,  47 


OBJECTIVE  signs  of  pregnancy,  60 
Obstetric  operations,  188 
Obstetrician,   articles  necessary   for, 
135 
attendance  of,  135 
Obstetrics,  definition  of,  17 
(Edema  of  vulva,  synonyms  for,  17 

treatment  of,  75 
Osiander's  signs  of  pregnancy,  56 
Outlet,  axis  of,  24 
Ovary,  changes  in,  at  puberty,  47 
development  of,  36 
functions  of,  29 
Ovarian  pregnancy,  94 
Ovaries,  changes  of,  in  pregnancy,  58 
Oviducts,  changes  in,  in  pregnancy, 
30 
uses  of,  29 
Ovisac,  causes  of  rupture  of,  47 
Ovulation,  47 

Ovule,  changes  in,  in  non-impreg- 
nated, 48 
passage  of,  through  oviduct,  48 
transfer  of,  to  oviduct,  49 
Ovum,  diseases  of,  81 

ectopic  development  of,  92 
morbid  anatomy  of,  81 


PALPATION  of  foetus,  118 
Parasitic  monsters,  164 
Pelvic  articulations,  relaxation  of,  76 
cavity,  diameters  of,  22 
deformities,  diagnosis  of,  172 
floor,  26 
inlet,  19 

diameters  of,  20 
joints,  18 
outlet,  20 

diameters  of,  21 
Pelvimetry,  external,  173 

internal,  174 
Pelvis,  anatomy  of,  17 
axes  of,  23 

changes  in  direction  of,  26 
contracted,  170 
deformities  of,  169 
form,  170 
position,  169 
size,  169 
divisions  of,  18 
generally   contracted,  diagnosis 

of,  175 
obliquity  of,  23 


INDEX. 


219 


Pelvis,  planes  of,  24 

simple  flat,  diagnosis  of,  175 

rachitic,  175 
soft  parts  of,  25 
Perineal  body,  27 
Perineum,  27 

development  of,  35 
dilatation  of,  in  labor,  112 
support  of,  139 
Phlebitis,  septic,  diagnosis  of,  185 
Placenta,  detachment  of,  112 
expulsion  of,  112 
functions  of,  33 
situation  of,  33 
Placenta  prasvia,  97 
causes  of,  99 
diagnosis  of,  99 
hemorrhage  in,  98 
treatment  of,  100 
Placental  circulation,  40 

decidua,  31 
Polyhydramnios,  83 
diagnosis  of,  84 
symptoms  of,  84 
treatment  of,  84 
Position,   diagnosis  of,  by  ausculta- 
tion, 117 
definition  of,  116 
number  of,  115 
Post-mortem  extraction  of  child,  213 
Post-partum  hemorrhage,  180 
Precocious  birth,  68 
Pregnancy,  after  menopause,  52 
certain  signs  of,  64 
diagnosis  of,  by  inspection,  61 
differential  diagnosis  of,  65 
divisions  of,  53 
duration  of,  68 

extra-uterine,  treatment  of,  96 
in  one-homed  uterus,  94 
primitive  cervical,  92 
prior  to  menstruation,  52 
Premature  labor,  induction  of,  190 
conditions  requiring, 

188 
indications  for,  188 
method  of  inducing,  189 
time  for  inducing,  188 
Presentation,  definition  of,  116 

diagnosis  of,  by  auscultation,  116 

by  indigation,  122 
number  of,  115 
Primitive  groove,  30 
Prolapse  of  cord,  166 


Prolapse    of   uterus,   indications    in 

treatment  of,  78 
Pruritus  vulvae,  77 
Puberty,  definition  of,  46 

changes  occurring  at,  47 
Puerperal  septicaemia,  1 82 

benign  form  of,  183 

course  of,  183 

grave  form  of.  184 

late  forms  of,  184 

RECTUM  in  labor,  attention  to,  154 
Restitution,  129 
Retention  of  urine,  81 
Retractility  of  uterus,  57 
Retroflexion  in  pregnancy,  results  of, 
79 
treatment  of,  80 
Retroversion  of  uterus  in  pregnancy, 

79 
Round  ligaments,  58 

SALIVATION,  treatment  of,  76 
Sanger's  operation,  209 
Semen,  fecundating  elements  of,  53 
Septic  lymphangitis,  185 

phlebitis,  185 
Septiceemia,  treatment  of,  185 
constitutional,  186 
curative,  185 
local,  185 
prophylactic,  186 
puerperal,  182 
Shoulders,  delivery  of,  in  head-first 
labors,  149 
diagnosis  of,  124 
positions  of,  126 
Signs  of  pregnancy,  certain,  64 
objective,  60 
subjective,  59 
Souffle,  cardiac,  64 

uterine,  64 
Sperm atozoids,  ascent  of,  54 

influence  on  later  pregnancies,  54 
number  of.  entering  ovule,  54 
Spondylotomy,  208 
Spontaneous  evolution,  stages  of,  134 
Super-fecundation,  69 
-foetation,  69 
-impregnation,  69 
Syeephalic  monsters,  162 
Symelic  monsters,  159 
Sysomic  monsters,  163 


220 


INDEX. 


TAMPON  in  abortion,  90 
Thrombus,  treatment  of,  76 
Touch,  signs  determined  by,  61 
Traction  in  labor,  140 
Tubal  pregnancy,  92 
Tubo-abdominal  pregnancy,  94 

-ovarian  pregnancy,  94 
Twin  birth,   arrest   of   delivery   in, 
164 
management  of,  165 
pregnancy,  appendages  in,  70 


UMBILICAL  cord,  33 
vesicle,  31 
Umbilicus,  changes  of,  in  pregnancy, 

55 
Uterine   appendages,  changes  of,  in 
pregnancy,  58 
contractions,  power  of,  109 
decidua,  31 
force,  deficiency  of,  154 

characteristics  of,  109 
souffle,  64 
Uterus,  anomalies  of,  36 

changes  of,  in  pregnancy,  56 
contractility  of,  57 
form  changes  of,  in  labor,  109 
functions  of,  29 
irritability  of,  57 
inversion  of,  178 
causes  of,  179 
symptoms  of,  179 
treatment  of,  179 
mucous  membrane  of,  in  preg- 
nancy, 31 
over-distention  of,  154 
properties  of,  in  pregnancy,  57 
retractility  of,  57 
rupture  of,  176 

causes  of  death  in,  1 78 
diagnosis  of,  176 


Uterus,  rupture  of,  due  to  thinning, 
mechanism  of,  176 

indications  in  treatment  of, 
178 

prophylactic  treatment  of, 
178 

threatened,  diagnosis  of,  176 

VAGINA,  changes  of,  in  pregnancy, 
56 
dilatation  of,  in  labor.  111 
functions  of,  28 
secretion  of,  28 
Varicosities  of  vulva,  treatment  of,  76 
Varicose  veins,  treatment  of,  75 
Vegetations  of  vulva,  treatment  of,  78 
Vein,  rupture  of,  treatment  of,  75 
Vernix  caseosa,  42 
Version,  192 

cephalic,  192 

conditions  necessary  for,  193 
indications  for,  193 
methods  of  performing,  192 
external  method  of,  194 
internal  method  of,  196 
pelvic,  194 

indications  for,  195 
method  of  performing,  195 
podalic,  195 

indications  for,  195 
methods  of  performing,  196 
Vertex,  positions  of,  124 
Vestibule,  29 
Vitelline  duct,  31 
Villi,  chorial,  31 
Vitellus,  30 
Vulva,  28 
Vulvo-vaginal  gland,  29 


WOLFFIAN  bodies,  35 


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